Portal hypertensive gastropathy and colopathy

Predictive factors of portal hypertensive enteropathy exacerbations based on long-term outcomes

BACKGROUND

Portal hypertensive enteropathy (PHE) is a small-bowel lesion observed in patients with portal hypertension. The clinical significance of endoscopic findings in PHE remains unclear. We aimed to clarify the clinical significance and predictive factors of capsule endoscopic findings in patients with PHE based on long-term outcomes.

METHODS

This retrospective study enrolled 55 patients with PHE (33 males and 22 females; median age, 64 years; range, 23-87) followed for > 3 years using capsule endoscopy (CE) between February 2009 and May 2023. We evaluated the clinical factors affecting PHE exacerbations and the effects of PHE exacerbations on gastrointestinal bleeding by comparing exacerbated and unchanged PHE groups.

RESULTS

Overall, 3 (5%) patients showed improvement, 33 (60%) remained unchanged, and 19 (35%) showed exacerbation on follow-up CE. In the exacerbated group, the rates of worsened fibrosis-4 index, exacerbated esophageal varices, and exacerbated portal hypertensive gastropathy were significantly higher than those in the unchanged group (21%, 32%, and 42% vs. 3%, 6%, and 12%, respectively; P < 0.05), and the rate of splenectomy was significantly lower in the exacerbated group than in the unchanged group (5% vs. 39%, respectively; P < 0.01). In multivariate analysis, exacerbation of esophageal varices and absence of splenectomy were significantly associated with PHE exacerbation. The rate of gastrointestinal bleeding after follow-up CE was significantly high in the exacerbated group (log-rank, P = 0.037).

CONCLUSIONS

Exacerbation of esophageal varices and splenectomy were significantly associated with exacerbation of PHE. Exacerbated PHE requires specific attention to prevent gastrointestinal bleeding.

Congestive colopathy in a patient with arteriovenous malformations and multiple mesenteric thromboses

Arteriovenous malformations (AVMs) in mesenteric vessels are exceptionally rare. These congenital vascular anomalies lead to direct vascular flow between the highly pressured arterial system and the low-pressure venous system. We describe the case of a patient with prior left colectomy for splenic flexure colonic adenocarcinoma presenting with persistent abdominal pain after developing multiple mesenteric thromboses. CT and colonoscopy showed left hemicolon congestion, anastomotic stenosis and mucosal oedema. Mesenteric angiogram revealed AVMs in the right colic and left colic arteries. Embolisation of the left colic AVM led to symptom resolution without recurrence at interval follow-up.

AGA Clinical Practice Update on Management of Iron Deficiency Anemia: Expert Review

DESCRIPTION

In this Clinical Practice Update (CPU), we will Best Practice Advice (BPA) guidance on the appropriate management of iron deficiency anemia.

METHODS

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Since systematic reviews were not performed, these BPA statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: No single formulation of oral iron has any advantages over any other. Ferrous sulfate is preferred as the least expensive iron formulation. BEST PRACTICE ADVICE 2: Give oral iron once a day at most. Every-other-day iron dosing may be better tolerated for some patients with similar or equal rates of iron absorption as daily dosing. BEST PRACTICE ADVICE 3: Add vitamin C to oral iron supplementation to improve absorption. BEST PRACTICE ADVICE 4: Intravenous iron should be used if the patient does not tolerate oral iron, ferritin levels do not improve with a trial of oral iron, or the patient has a condition in which oral iron is not likely to be absorbed. BEST PRACTICE ADVICE 5: Intravenous iron formulations that can replace iron deficits with 1 or 2 infusions are preferred over those that require more than 2 infusions. BEST PRACTICE ADVICE 6: All intravenous iron formulations have similar risks; true anaphylaxis is very rare. The vast majority of reactions to intravenous iron are complement activation-related pseudo-allergy (infusion reactions) and should be treated as such. BEST PRACTICE ADVICE 7: Intravenous iron therapy should be used in individuals who have undergone bariatric procedures, particularly those that are likely to disrupt normal duodenal iron absorption, and have iron-deficiency anemia with no identifiable source of chronic gastrointestinal blood loss. BEST PRACTICE ADVICE 8: In individuals with inflammatory bowel disease and iron-deficiency anemia, clinicians first should determine whether iron-deficiency anemia is owing to inadequate intake or absorption, or loss of iron, typically from gastrointestinal bleeding. Active inflammation should be treated effectively to enhance iron absorption or reduce iron depletion. BEST PRACTICE ADVICE 9: Intravenous iron therapy should be given in individuals with inflammatory bowel disease, iron-deficiency anemia, and active inflammation with compromised absorption. BEST PRACTICE ADVICE 10: In individuals with portal hypertensive gastropathy and iron-deficiency anemia, oral iron supplements initially should be used to replenish iron stores. Intravenous iron therapy should be used in patients with ongoing bleeding who do not respond to oral iron therapy. BEST PRACTICE ADVICE 11: In individuals with portal hypertensive gastropathy and iron-deficiency anemia without another identified source of chronic blood loss, treatment of portal hypertension with nonselective β-blockers can be considered. BEST PRACTICE ADVICE 12: In individuals with iron-deficiency anemia secondary to gastric antral vascular ectasia who have an inadequate response to iron replacement, consider endoscopic therapy with endoscopic band ligation or thermal methods such as argon plasma coagulation. BEST PRACTICE ADVICE 13: In patients with iron-deficiency anemia and celiac disease, ensure adherence to a gluten-free diet to improve iron absorption. Consider oral iron supplementation based on the severity of iron deficiency and patient tolerance, followed by intravenous iron therapy if iron stores do not improve. BEST PRACTICE ADVICE 14: Deep enteroscopy performed in patients with iron-deficiency anemia suspected to have small-bowel bleeding angioectasias should be performed with a distal attachment to improve detection and facilitate treatment. Small-bowel angioectasias may be treated with ablative thermal therapies such as argon plasma coagulation or with mechanical methods such as hemostatic clips. BEST PRACTICE ADVICE 15: Endoscopic treatment of angioectasias should be accompanied with iron replacement. Medical therapy for small-bowel angioectasias should be reserved for compassionate treatment in refractory cases when iron replacement and endoscopic therapy are ineffective.

Role of Endoscopy in the Diagnosis, Grading, and Treatment of Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are 2 distinct gastric vascular abnormalities that may present with acute or chronic blood loss. PHG requires the presence of portal hypertension and is typically associated with chronic liver disease, whereas there is controversy about the association of GAVE with chronic liver disease and/or portal hypertension. Distinguishing between GAVE and PHG is crucial because their treatment strategies differ. This review highlights characteristic endoscopic appearances and the clinical features of PHG and GAVE, which, in turn, aid in their appropriate management.

Portal Hypertension in Malnutrition and Sarcopenia in Decompensated Cirrhosis-Pathogenesis, Implications and Therapeutic Opportunities

Malnutrition and sarcopenia are highly prevalent in patients with decompensated cirrhosis and are associated with poorer clinical outcomes. Their pathophysiology is complex and multifactorial, with protein-calorie malnutrition, systemic inflammation, reduced glycogen stores and hormonal imbalances all well reported. The direct contribution of portal hypertension to these driving factors is however not widely documented in the literature. This review details the specific mechanisms by which portal hypertension directly contributes to the development of malnutrition and sarcopenia in cirrhosis. We summarise the existing literature describing treatment strategies that specifically aim to reduce portal pressures and their impact on nutritional and muscle outcomes, which is particularly relevant to those with end-stage disease awaiting liver transplantation.

Newly diagnosed cirrhosis secondary to gastrointestinal bleed due to portal hypertensive colopathy

Portal hypertensive colopathy (PHC) is a colonic phenomenon commonly causing chronic gastrointestinal bleeding or less commonly a life-threatening acute colonic hemorrhage. An otherwise well, 58-year-old female presents general surgeons a diagnostic dilemma for symptomatic anemia. An interesting case where the rare and elusive PHC was diagnosed on colonoscopy, which led to the diagnosis of liver cirrhosis without evidence of oesophageal varices. Although PHC is most common in patients with cirrhosis, it is likely still underdiagnosed, given the current stepwise treatment approach of these cirrhotic patients often leads to treatment of the PHC alongside PHG without establishing a diagnosis. Instead, this case presents a generalised approach to patients with underlying portal and sinusoidal hypertension due to a variety of causes, and the endoscopic and radiological findings, which lead to their successful diagnosis and medical management of the gastrointestinal bleeding.

Gastric Histopathologic Findings Are Similar in Portal Hypertension Patients With and Without Endoscopic Portal Hypertensive Gastropathy

OBJECTIVES

Portal hypertensive gastropathy (PHG) is a diagnosis made based on endoscopic findings in the appropriate clinical setting. Biopsy may be taken during endoscopy for correlation, but the pathologist may encounter a myriad of nonspecific histologic findings. We undertook this study to evaluate contexts where a histologic diagnosis of PHG might be rendered on biopsy.

METHODS

Two cohorts were established: stomach biopsy specimens from patients with cirrhosis or undergoing varices screening (n = 188) and stomach biopsy specimens with findings interpreted as PHG in the pathology report (n = 29).

RESULTS

In the first cohort, cases with endoscopic varices more frequently displayed foveolar hyperplasia and acute inflammation, with no other histologic differences between cases with and without endoscopic PHG, clinical varices, and clinical cirrhosis. Cases from the second cohort showed no histologic differences when stratified for endoscopic PHG, endoscopic varices, and clinical cirrhosis. Our second cohort displayed the majority of charted histologic findings more frequently than the first. Our results indicate that neither an endoscopic appearance of PHG nor particular clinical diagnoses associated with PHG translate into specific histologic findings.

CONCLUSIONS

Although the histologic findings charted displayed increased frequency in pathology reports with an interpretation of PHG, histology should not be used reliably in the diagnosis of PHG.

Banti's Syndrome in an Adult Male: A Case Report

Banti’s syndrome is a chronic congestive enlargement of the spleen leading to the destruction of blood cells resulting in pancytopenia. It is also associated with cirrhosis and ascites along with symptoms of pancytopenia such as infection, bruising, weakness, and fatigue. Multiple factors such as hepatitis B infection, coagulation abnormalities and exposure to arsenic, etc. may also cause Banti’s syndrome. Clinical evaluation with blood profile along with use of imaging studies such as MRI and splenic venography is utilized for the determination of Banti’s syndrome. In this report, we present a 29-year-old diabetic male who presented with abdominal distention, right leg cellulitis, fever, and a past history of hematemesis and melena. On examination, distended abdomen showed marked splenomegaly with ascites (positive shifting dullness and fluid thrill). Also, the left leg was warm, swollen, and tender to the touch. Complete blood count showed decreased WBC, RBC, Hb, with peripheral smear negative for malarial parasites. Ultrasound scan of abdomen and pelvis was done illustrating massive splenomegaly with pelvic dilation and ascites.

Lactulose-Induced Ischemic Colitis: A Rare Presentation and an Overview of Possible Etiologies of the Disease

Ischemic colitis is one of the most common ischemic pathologies of the gastrointestinal system and can be divided into non-gangrenous and gangrenous forms. The pathophysiology involves restricted blood supply to the colonic mucosa. Several risk factors have been implicated in the development of ischemic colitis. Lactulose, one of the mainstay therapies for the treatment of hepatic encephalopathy in patients with cirrhosis, has been rarely reported as a cause of ischemic colitis. To the best of our knowledge, there has been only one case report associating lactulose use with the development of ischemic colitis. The exact pathophysiology is unknown but might be associated with the fermentation of lactulose by intestinal bacteria, causing gaseous distention and increasing the intraluminal pressure. We present the case of a 77-year-old African American male, a known case of non-alcoholic liver cirrhosis with portal hypertension and esophageal varices, brought in by his family to the emergency department for altered mental status, non-bilious vomiting, abdominal distension, and pain for one day. On physical examination, the patient had upper extremity asterixis and was alert but disoriented to place and person. Diagnostic paracentesis was performed, which revealed leukocytosis, predominantly neutrophils. The patient was admitted for spontaneous bacterial peritonitis and hepatic encephalopathy with decompensated liver cirrhosis. The patient was started lactulose with a goal of three to four bowel movements per day. Despite adequate treatment, the patient continued to develop worsening mental function and abdominal distension. This was later followed by a bloody bowel movement. Laboratory assessment showed an elevated white blood cell count, worsening kidney function, and high anion gap metabolic acidosis. CT scan revealed dilated loops of bowel with air and fluid along with submucosal wall edema, findings suggestive of ischemic colitis. Given the poor prognosis and the patient's condition, colonoscopy was deferred. Lactulose was discontinued, as it was thought to be a contributing cause of the patient's ischemic colitis. His condition continued to deteriorate, and he passed away on Day 18 of admission.

The relationship between portal hypertension and portal hypertensive gastropathy

BACKGROUND AND AIM

Portal hypertensive gastropathy (PHG) most commonly occurs in the setting of increased portal pressure in patients with cirrhosis. Here, we aimed to understand the correlation between hepatic venous pressure gradient (HVPG) and the presence and severity of PHG in patients with cirrhosis.

METHODS

We examined patients with cirrhosis who underwent HVPG measurement at the Medical University of South Carolina between 2014 and 2020. Extensive demographic, clinical, laboratory, procedural (including precise grading of PHG severity using standard definitions), and outcome data were abstracted at the time of HVPG measurement.

RESULTS

Three hundred and ten patients with HVPG measurements and cirrhosis were identified. Seventy-three patients having endoscopy within 6 months of HVPG measurement were included (mean age 54 ± 11, 44% female). The most common causes of cirrhosis were alcohol (41%) and non-alcoholic steatohepatitis (32%). The average HVPG was 15 mmHg (±6) and 62 patients had clinically significant portal hypertension (CSPH) (HVPG ≥ 10 mmHg). Of the 73 patients with HVPG measured, 45 (62%) had PHG, including 40 (89%) of whom had CSPH. Out of the 45 patients with PHG, 41 and four had mild or severe PHG, respectively. MELD scores were similar in patients with and without PHG [15 ± 9 (SD) and 17 ± 9, respectively; p = .37]. HVPG was higher in patients with PHG (17 ± 7 mmHg) than those without PHG (13 ± 4 mmHg) (p = .01) but did not differ between mild and severe PHG.

CONCLUSION

A weak correlation exists between HVPG level and the presence of PHG.

Comparison of portal hypertensive gastropathy and gastric antral vascular ectasia: an update

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are two distinct entities that are frequently mistaken with each other, because they present with similar manifestations. This issue may cause catastrophic outcomes, as each one of them has a unique pathophysiology, thereby making their management approaches completely different. There are clinical clues that help physicians distinguish these two. Direct vision via upper endoscopy is often mandatory to establish the diagnosis, and sometimes biopsy is required. In this review, we sought to discuss different aspects of both conditions and highlight clinical evidence that may help in identifying and managing the disease appropriately.

Correlation of endoscopic findings with Doppler ultrasound in portal hypertension in children

Aim of the study

To determine the correlation of the endoscopic findings with portal Doppler and ultrasound (USG) in children with suspected portal hypertension (PHT).

Material and methods

Eighty children with extrahepatic portal vein obstruction (EHPVO) and chronic liver disease (CLD) were included in this retrospective study conducted over a period of 1 year. All patients underwent upper gastrointestinal (GI) endoscopy and Doppler.

Results

The etiology was EHPVO in 30 (37.5%) patients, biliary atresia in 12 (15%), Budd-Chiari syndrome in 11 (13.7%), Wilson’s disease in 10 (12.5%), idiopathic CLD in 8 (10%), autoimmune hepatitis in 4 (5%), glycogen storage disease (GSD) in 3 (3.8%), non-alcoholic liver disease (NAFLD) in 1 (1.3%) and systemic lupus erythematosus (SLE) in 1 (1.3%) patient. Fifty-three (66.25%) patients had esophageal varices on endoscopy, of whom 3 (3.8%) had associated gastric varices. Portal hypertensive gastropathy (PHG) was present in 30 (37.5%) patients, of whom 10 (12.5%) had severe PHG. Forty-one (51.3%) patients had PHT on Doppler (κ correlation 0.43). Kappa correlation was 0.43 in patients with biliary atresia, 0.31 in Budd-Chiari syndrome, 0.23 in idiopathic CLD, 0.21 in CLD, and 0.05 in Wilson’s disease. All (100%) EHPVO patients and 39 (78%) CLD patients had PHT on USG. Endoscopic findings of PHT were seen in 24 (80%) EHPVO patients and 29 (58%) CLD patients. All patients with EHPVO had cavernous transformation of the portal vein on Doppler. For patients with CLD, the common Doppler findings were collaterals seen in 35 patients and reversal of flow in 12 patients.

Conclusions

Doppler ultrasound followed by endoscopy should be used to diagnose PHT in children. In children with biliary atresia, Doppler ultrasound may miss changes of PHT.

Pearls, Pitfalls, and Conditions that Mimic Mesenteric Ischemia at CT

Acute mesenteric ischemia (AMI) is a life-threatening condition with a high mortality rate. The diagnosis of AMI is challenging because patient symptoms and laboratory test results are often nonspecific. A high degree of clinical and radiologic suspicion is required for accurate and timely diagnosis. CT angiography of the abdomen and pelvis is the first-line imaging test for suspected AMI and should be expedited. A systematic "inside-out" approach to interpreting CT angiographic images, beginning with the bowel lumen and proceeding outward to the bowel wall, mesentery, vasculature, and extraintestinal viscera, provides radiologists with a practical framework to improve detection and synthesis of imaging findings. The subtypes of AMI are arterial and venoocclusive disease, nonocclusive ischemia, and strangulating bowel obstruction; each may demonstrate specific imaging findings. Chronic mesenteric ischemia is more insidious at onset and almost always secondary to atherosclerosis. Potential pitfalls in the diagnosis of AMI include mistaking pneumatosis as a sign that is specific for AMI and not an imaging finding, misinterpretation of adynamic ileus as a benign finding, and pseudopneumatosis. Several enterocolitides can mimic AMI at CT angiography, such as inflammatory bowel disease, infections, angioedema, and radiation-induced enterocolitis. Awareness of pitfalls, conditions that mimic AMI, and potential distinguishing clinical and imaging features can assist radiologists in making an early and accurate diagnosis of AMI. ^©RSNA, 2020.

Chinese guidelines on the management of liver cirrhosis (abbreviated version)

Based on reviews of the literature and experts' consensus, the Chinese Society of Hepatology developed guidelines for the diagnosis and treatment of liver cirrhosis, in order to improve clinical practice. In addition to what has been covered in previously published guidelines on the management of cirrhosis complications, these guidelines add new sections and provide updates. The guidelines emphasize the early diagnosis of the cause and assessment of complications. Comprehensive treatments including etiological treatment and complication management should be initiated immediately. In addition, regular monitoring, especially surveillance of hepatocellular carcinoma, is crucial for managing patients.

Increases in Autoantibody Level Associated with Degenerative Changes in the Intestinal Mucosa in Liver Cirrhosis

Background

Portal hypertensive colonopathy is a consequence of portal hypertension that develops in hepatic cirrhosis. Pathological processes occurring in intestinal epithelium cells can be revealed by changes in the autoantibody titers to intestinal antigens. It is important both in diagnosis and in the evaluation of the treatment effectiveness.

Purpose

To investigate the effect of portal hypertension in patients with liver cirrhosis on degenerative processes in the walls of the small and large intestines after stimulation of liver regeneration with cryoprecipitate.

Methods

Thirty-six patients with liver cirrhosis underwent a procedure for percutaneous introduction of cryoprecipitate into the liver tissue. Before and 1 year after it, all the patients were measured for portal blood flow parameters, performed colonoscopy with biopsy, and determined autoantibodies to intestinal antigens (ItM, SCM) in the blood. Comparative analyses of changes in the large intestine mucosa before and after reducing portal hypertension by stimulating liver regeneration with cryoprecipitate were conducted.

Results

Here, we show that the degenerative process in the mucosa of the intestines increases, despite the positive dynamics of portal blood flow parameters after the liver regeneration. Autoantibodies values for the intestine antigens were higher than normal in 22 of the 36 patients after 1 year of introduction of cryoprecipitate into the liver. Morphological analysis of the intestinal wall showed the presence of edema/mucosal atrophy and neutrophilic/lymphocytic-histiocytic infiltration in 28 of the 36 patients.

Conclusion

Changes in autoantibodies to intestinal antigens are an informative method for diagnosing colonopathy and enteropathy at early stages, providing the possibility to administer proper timely treatment. Patients with hepatic cirrhosis are recommended to have their intestinal microflora tested and be administered drugs that improve their composition.

Prevalence, nature, and predictors of colonic changes in children with extrahepatic portal vein obstruction

BACKGROUND AND AIMS

The medical literature on colonic changes in children with extrahepatic portal venous obstruction (EHPVO) is limited. We evaluated EHPVO children for prevalence, nature, and relation of colonic changes with disease duration, extent of splenoportal axis (SPA) thrombosis, portal hypertensive gastropathy (PHG), and esophageal varices (EVs). The correlation between histologic and endoscopic changes was studied.

METHODS

Subjects were evaluated by colonoscopy with ileoscopy and biopsy sampling, clinico-laboratory profiles, and SPA imaging. Colonic changes were classified as varices (rectal/colonic) and portal hypertensive colopathy (PHC; colitis-like or vascular lesions). Morphometric analysis of colonic biopsy specimens was performed.

RESULTS

Fifty-four children (median age, 12 years [range, 8-15]; hematochezia in 9 [16.6%]) were evaluated. Rectal and colonic varices were seen in 51 (94%) and 2 (3.7%) cases, respectively. Seventy-five percent of patients had PHC, and colitis-like lesions were more common than vascular lesions (36/40 vs 23/40; P = .001). Colopathy changes were pancolonic in 52.5%, left-sided in 42.5%, and right-sided in 5% of cases. Sixteen percent of patients (8/49) had ileal changes. Children with PHC had PHG more often (90% vs 57%; P = .01), more endotherapy sessions (mean 6 [range, 4-8] vs 2 [range, 1-4]; P = .03), and large EVs less often (12.5% vs 43%; P = .02) than those without colopathy. The extent of SPA thrombosis was similar in patients with and without PHC. The number of capillaries per crypt was higher in EHPVO than in control subjects. Morphometric changes had no correlation with endoscopy.

CONCLUSIONS

Most EHPVO children had colonic changes, and 16% had ileopathy. "Colitis-like" changes and left-side involvement were more common. Patients with PHG and eradicated EVs had a higher risk of PHC.

Portal hypertensive gastropathy is associated with iron deficiency anemia

Background and aims

Portal hypertensive gastropathy (PHG) is common in patients with cirrhosis and may cause bleeding. This study systematically explored the independent impact of patient characteristics, portal hypertension and hepatic dysfunction on PHG severity and associated anemia.

Methods

Patients with cirrhosis undergoing endoscopy were included in this retrospective analysis and PHG was endoscopically graded as absent, mild or severe. Clinical and laboratory parameters and hepatic venous pressure gradient (HVPG) were assessed with respect to an association with severity of PHG.

Results

A total of 110 patients (mean age: 57 years, 69% male) with mostly alcoholic liver disease (49%) or viral hepatitis (30%) were included: 15 (13.6%) patients had no PHG, 59 (53.6%) had mild PHG, and 36 (32.7%) had severe PHG. Severe PHG was significantly associated with male sex (83.3% vs. 62.2% in no or mild PHG; p = 0.024) and higher Child-Turcotte-Pugh (CTP) stage (CTP-C: 38.9% vs. 27.0% in no or mild PHG; p = 0.030), while MELD was similar (p = 0.253). Patients with severe PHG had significantly lower hemoglobin values (11.2 ± 0.4 g/dL vs. 12.4 ± 0.2 g/dL; p = 0.008) and a higher prevalence of iron-deficiency anemia (IDA: 48.5% vs. 26.9%; p = 0.032). Interestingly, HVPG was not significantly higher in severe PHG (median 20 mm Hg) vs. mild PHG (19 mm Hg) and no PHG (18 mm Hg; p = 0.252). On multivariate analysis, CTP score (odds ratio, OR: 1.25, 95% confidence interval, CI 1.02–1.53; p = 0.033) was independently associated with severe PHG, while only a trend towards an independent association with IDA was observed (OR: 2.28, 95% CI 0.91–5.72; p = 0.078).

Conclusion

The CTP score but not HVPG or MELD were risk factors for severe PHG. Importantly, anemia and especially IDA are significantly more common in patients with severe PHG.

Electronic supplementary material

The online version of this article (10.1007/s00508-019-01593-w) contains supplementary material, which is available to authorized users.

An Update: Portal Hypertensive Gastropathy and Colopathy

Complications of portal hypertension include portal hypertensive gastropathy and colopathy. These disorders may cause chronic or acute gastrointestinal bleeding. The diagnosis is made endoscopically; therefore, there is great variability in their assessment. Portal hypertensive gastropathy can range from a mosaic-like pattern resembling snakeskin mucosa to frankly bleeding petechial lesions. Portal hypertensive colopathy has been less well-described and is variably characterized (erythema, vascular lesions, petechiae). Treatment is challenging and results are inconsistent. Currently, available evidence does not support the use of beta-blockers for primary prevention. Further investigation of the pathogenesis, natural history, and treatment of these disorders is needed.

Significant of adiponectin in gastropathy: Case-controlled study

Background

Gastropathy is a medical broad term applied for stomach diseases that affect mucosal lining characterized by epithelial injury. There are many types of gastropathy ranging from harmless conditions to more serious ones like cancer.

Aim of the study

to assess the significant effect of adiponectin and its level in patients with gastropathy.

Patients and methods

This case-control study includes 35 patients with gastropathy confirmed by gastroscope and thirty control group. Anthropometric Measurements like Weight, height, waist circumference, body mass index, and waist circumference. Blood sample was collected from the patients and control group and serum tested for lipid profile that includes (cholesterol, triglyceride, HDLP, LDLP) (Human-Germany), and adiponectin (Shanghai Biologic Technology-China) using Enzyme-Linked Immunosorbent Assay (ELISA).

Results

There is a significant difference between the two groups regarding height, weight, waist circumference, and waist to hip ratio (P-value 0.002,0.009, 0.002 and 0.015 respectively). Regarding adiponectin, there is no significant difference between patients (9.54 ± 5.821 and control 9.119 ± 7.062)(P = 0.796). Lipid profile showed a significant increase in cholesterol (p = 0.0001) and triglyceride (0.007) in patients group while there is no significant difference in HDL, LDL and LDL/HDL ratio.

Conclusions

Adiponectin had no role in the development of gastropathy. Patients with gastropathy had a significant increase in the serum level of cholesterol and triglyceride. There is a significant negative correlation between adiponectin and weight, body mass index, waist circumference, triglyceride, and low-density lipoprotein.

•

Gastropathy is a medical broad term applied for stomach diseases.

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Effect of adiponectin and its level in patients with gastropathy.

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This case-control study includes 35 patients with gastropathy confirmed by gastroscope and thirty control group.

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Anthropometric Measurements and blood sample were collected from two groups.

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There is a significant difference between two groups regarding height, weight, waist circumference and waist to hip ratio while adiponectin there is no significant difference between two groups.

Management of a Portal Hypertensive Polyp: Case Report of a Rare Entity

Portal hypertensive polyposis is a rare finding represented in about 2.5% of all patients with portal hypertension. The diagnostic criteria are not yet clearly defined. It has been mentioned in a few case reports; its distribution was mainly duodenal and less frequently gastric. Here, a patient with type 2 diabetes and liver cirrhosis was hospitalized for vomiting, abdominal pain, and melena. The patient was admitted to the intensive care unit for stabilization and urgent esophagogastroduodenoscopy (EGD). EGD revealed a single antral polyp occluding the pyloric ring which was the cause of gastric outlet obstruction. Complete debulking by argon plasma was done which improved gastric outlet obstruction and melena. We conclude that argon plasma coagulation is a safe, rapid, and effective method for treating portal hypertensive polyposis.

[Some practical issues in the management of patients with decompensated liver cirrhosis]

The natural course of cirrhosis is characterized by a shift from a compensated stage without clinical manifestations to a subsequent decompensated stage, which is characterized by the development of obvious clinical symptoms, the most frequent of which are ascites, bleeding from varicose veins, bacterial infections, encephalopathy. The articles and reviews of recent years emphasize the importance of etiotropic treatment of liver cirrhosis at any stage, including the final one. In addition, pathogenetic and symptomatic therapy aimed at treating complications of cirrhosis of the liver: ascites, dilution hyponatremia, gastrointestinal bleeding, bacterial infections, and kidney damage comes to the forefront at the stage of decompensation, which allows the patient to be on the waiting list for liver transplantation. This category of patients, as a rule, is difficult to treat and has features and subtleties of reference.

Five-year-term results in cirrhotics without varices, either affected or not by portal hypertensive gastropathy

OBJECTIVES

Information is lacking on the appearance of varices in cirrhotics, either affected or not by portal hypertensive gastropathy (PHG). We assessed whether the absence or presence and the grade of PHG influenced the development of varices in cirrhotics without varices over time.

PATIENTS AND METHODS

Forty cirrhotics without varices affected or not by PHG at baseline underwent follow-up endoscopy after 5 years. One-tailed t-test and the χ-test were used to evaluate variable comparison and the presence of associations. Multivariate logistic regression analysis and the analysis of variance test were carried out to compare the variables and identify predictors of varices.

RESULTS

The Child-Pugh score at baseline and after 5 years was significantly different (5.72±0.98 vs. 6.25±1.67, P<0.001). After 5 years, 10 (25%) cirrhotics were affected by varices, whereas 30 (75%) patients remained without varices. PHG was associated significantly with varices (P=0.001), proving to be a significant predictive independent factor for their development over time (F=4.765, significant=0.004; analysis of variance test, P<0.001).

CONCLUSION

A link between the duration of PHG and the development of varices is likely. An early therapeutic management of PHG might delay the development of varices in cirrhotics.

Safety and Efficacy of a Novel Shunt Surgery Combined with Foam Sclerotherapy of Varices for Prehepatic Portal Hypertension: A Pilot Study

OBJECTIVES

This pilot study investigated the safety and efficacy of a novel shunt surgery combined with foam sclerotherapy of varices in patients with prehepatic portal hypertension.

METHODS

Twenty-seven patients who were diagnosed with prehepatic portal hypertension and underwent shunt surgeries were divided into three groups by surgery type: shunt surgery alone (Group A), shunt surgery and devascularization (Group B), and shunt surgery combined with foam sclerotherapy (Group C). Between-group differences in operation time, intraoperative blood loss, portal pressure decrease, postoperative complications, rebleeding rates, encephalopathy, mortality rates and remission of gastroesophageal varices were compared.

RESULTS

Groups A, B and C had similar operation times, intraoperative bleeding, and portal pressure decrease. The remission rates of varices differed significantly (p<0.001): one patient in Group A and 6 patients in Group B had partial response, and all 9 patients in Group C had remission (2 complete, 7 partial). Two Group A patients and one Group B patient developed recurrent gastrointestinal bleeding postoperatively within 12 months. No postoperative recurrence or bleeding was observed in Group C, and no sclerotherapy-related complications were observed.

CONCLUSIONS

Shunt surgery combined with foam sclerotherapy obliterates varices more effectively than shunt surgery alone does, decreasing the risk of postoperative rebleeding from residual gastroesophageal varices. This novel surgery is safe and effective with good short-term outcomes.

Gastrointestinal Bleeding Secondary to Portal Hypertensive Duodenopathy in a Patient with Decompensated Liver Cirrhosis

With alcoholic cirrhosis and nonalcoholic fatty liver disease continuously on the rise in the United States, there is also a corresponding rise in portal hypertension. Portal hypertensive duodenopathy (PHD) is a complication of portal hypertension not commonly seen in cirrhotic patients. We present a case of a 46-year-old man who presented with decompensated liver cirrhosis secondary to gastrointestinal bleed. The patient underwent esophagogastroduodenoscopy (EGD) with findings indicative of PHD. Patient subsequently underwent transjugular intrahepatic portosystemic shunt (TIPS) with resolution of gastrointestinal bleed. We highlight TIPS as a management strategy in patients with PHD for whom less invasive measures are not effective.

Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III)

The Billroth III guidelines were developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on 18 February 2017 in Vienna. Based on international guidelines and considering recent landmark studies, the Billroth III recommendations aim to help physicians in guiding diagnostic and therapeutic strategies in patients with portal hypertension.

Noninvasive Clinical Predictors of Portal Hypertensive Gastropathy in Patients with Liver Cirrhosis

BACKGROUND AND OBJECTIVES

Portal hypertensive gastropathy (PHG) is described endoscopically as "mosaic-like appearance" of gastric mucosa with or without the red spots. It can only be diagnosed by upper gastrointestinal (GI) endoscopy. The aim of this study was to determine the diagnostic accuracy of platelet count to spleen diameter ratio (PSR) and right liver lobe diameter to albumin ratio (RLAR) in the detection of PHG using upper GI endoscopy as a gold standard in patients with liver cirrhosis.

MATERIAL AND METHODS

This cross-sectional study was conducted in the Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi. All consecutive patients with ages 18-65 years who were screened using esophagogastroduodenoscopy (EGD) to exclude esophageal varices were enrolled. At the same time, findings related to PHG were noted. After informed consent, all the patients had blood tests including platelet count and albumin and abdominal ultrasound determining spleen diameter and right liver lobe diameter.

RESULTS

Out of 111 patients, 59 (53.15%) were males with a mean age of 44 ± 12.61 years. Rate of PHG was observed in 84.68% (94/111) cases confirmed by EGD. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of PSR were 87.23%, 5.88%, 83.67%, 7.69%, and 74.7%, respectively, and those of RLAR were 28.72%, 70.59%, 84.38%, 15.19%, and 35.14%, respectively.

CONCLUSION

PSR is better predictor of PHG than RLAR but at the expense of relatively lower specificities and NPV likely because of underlying pathophysiology (portal hypertension) which is similar for esophageal varices, PHG, and ascites.

Diagnostic and therapeutic features of small bowel involvement in portal hypertension

Enteropathy is a lesser known complication of portal hypertension and consists of different changes in the mucosal layer of the small bowel which lead to the appearance of vascular and inflammatory lesions. It can be an important co-factor in the development of anemia in the cirrhotic population, and nowadays an easy and non-invasive diagnosis can be made thanks to capsule endoscopy. However, it is rarely considered in the management of patients with portal hypertension. Some aspects such as pathogenesis or incidence remain unclear and no specific recommendations are included in the guidelines regarding diagnosis or treatment. A review of the available literature was performed with regards to the most relevant aspects of this entity.

Acute on chronic gastrointestinal bleeding: a unique clinical entity

Gastrointestinal bleeding is defined in temporal-spatial terms-as acute or chronic, and/or by its location in the gastrointestinal tract. Here, we define a distinct type of bleeding, which we have coined 'acute on chronic' gastrointestinal bleeding. We prospectively identified all patients who underwent endoscopic evaluation for any form of gastrointestinal bleeding at a University Hospital. Acute on chronic bleeding was defined as the presence of new symptoms or signs of acute bleeding in the setting of chronic bleeding, documented as iron deficiency anemia. Bleeding lesions were categorized using previously established criteria. We identified a total of 776, 254, and 430 patients with acute, chronic, or acute on chronic bleeding, respectively. In patients with acute on chronic gastrointestinal bleeding, lesions were most commonly identified in esophagus (28%), colon and rectum (27%), and stomach (21%) (p<0.0001 vs locations for acute or chronic bleeding). In those specifically with acute on chronic upper gastrointestinal bleeding (n=260), bleeding was most commonly due to portal hypertensive lesions, identified in 47% of subjects compared with 29% of acute and 25% of chronic bleeders, (p<0.001). In all patients with acute on chronic bleeding, 30-day mortality was less than that after acute bleeding alone (2% (10/430) vs 7% (54/776), respectively, p<0.001). Acute on chronic gastrointestinal bleeding is common, and in patients with upper gastrointestinal bleeding was most often a result of portal hypertensive upper gastrointestinal tract pathology. Reduced mortality in patients with acute on chronic gastrointestinal bleeding compared with those with acute bleeding raises the possibility of an adaptive response.

Screening by Total Colonoscopy Following Fecal Immunochemical Tests and Determinants of Colorectal Neoplasia in Japanese Men With Alcohol Dependence

Aims

Alcohol consumption increases the risk of colorectal adenoma and cancer. The fecal immunochemical test (FIT) is a widely used screening method for detecting colorectal neoplasia. We evaluated the results of screening and risk factors for colorectal neoplasia in individuals with alcohol dependence.

Methods

Total colonoscopic screening was performed for 1006 Japanese men with alcohol dependence (462 FIT-positive and 544 FIT-negative). Advanced neoplasia was defined as neoplasia ≥10 mm, villous or tubulovillous adenoma, high-grade adenoma, or carcinoma.

Results

The detection rates for non-advanced adenoma, advanced neoplasia and intramucosal or invasive carcinoma were 38.7%, 39.4% and 9.7% for the FIT-positive group, and 33.3%, 10.8% and 2.2% for the FIT-negative group, respectively. Advanced neoplasia, especially carcinoma, was detected more frequently in the distal colon than in the proximal colon in the FIT-positive group. The respective multivariate odds ratios (ORs; 95% confidence interval) for non-advanced adenoma and advanced neoplasia were 2.83 (2.06–3.88) and 9.13 (6.19–13.5) for a positive FIT (vs. negative), 1.68 (1.39–2.02) and 1.83 (1.45–2.30) for age (per +10 years), 1.54 (1.06–2.23) and 1.88 (1.17–3.03) for current smoking (vs. non-smokers), and 1.35 (0.96–1.92) and 1.59 (1.02–2.48) for the presence of marked macrocytosis (mean corpuscular volume ≥106 fl vs. <106 fl). Genetic polymorphisms of alcohol dehydrogenase-1B and aldehyde dehydrogenase-2 did not affect the risk of colorectal neoplasia.

Conclusion

The detection rate for advanced colorectal neoplasia was extremely high in the FIT-positive group but remained high even in the FIT-negative group. An older age, smoking and macrocytosis were predictors of advanced colorectal neoplasia.

Short summary

Total colonoscopic screening was performed for 1006 Japanese alcoholic men (462 fecal immunochemical test [FIT]-positive and 544 FIT-negative). The detection rate for advanced colorectal neoplasia was extremely high in the FIT-positive group (39.4%) and high in the FIT-negative group (10.8%). Ageing, smoking and macrocytosis were predictors of advanced colorectal neoplasia.

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

AIM

To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy (PHG) based on a systematic literature review.

METHODS

Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "portal" and "gastropathy"; or "portal" and "hypertensive"; or "congestive" and "gastropathy"; or "congestive" and "gastroenteropathy". The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG.

RESULTS

PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG. PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepatic-portosystemic-shunt and liver transplantation are highly successful ultimate therapies because they reduce the underlying portal hypertension.

CONCLUSION

PHG is important to recognize in patients with cirrhotic or non-cirrhotic portal hypertension because it can cause acute or chronic GI bleeding that often requires pharmacologic therapy.

Duodenal polyposis secondary to portal hypertensive duodenopathy

Portal hypertensive duodenopathy (PHD) is a recognized, but uncommon finding of portal hypertension in cirrhotic patients. Lesions associated with PHD include erythema, erosions, ulcers, telangiectasia, exaggerated villous pattern and duodenal varices. However, duodenal polyposis as a manifestation of PHD is rare. We report a case of a 52-year-old man who underwent esophagogastroduodenoscopy and was found with multiple small duodenal polyps ranging in size from 1-8 mm. Biopsy of the representative polyps revealed polypoid fragments of duodenal mucosa with villiform hyperplasia lined by reactive duodenal/gastric foveolar epithelium and underlying lamina propria showed proliferating ectatic and congested capillaries. The features were diagnostic of polyps arising in the setting of PHD.

Prevalence, variability, and outcomes in portal hypertensive colopathy: a study in patients with cirrhosis and paired controls

BACKGROUND

Management of portal hypertensive colopathy (PHC) has been challenged by controversial results in its prevalence and clinical relevance.

OBJECTIVE

To describe the PHC prevalence and to evaluate the variability in diagnosis, the relation to severity of liver disease, and the incidence of severe outcomes.

DESIGN

Cross-sectional study.

SETTING

Endoscopic unit of a tertiary-care academic center in Rio de Janeiro, Brazil.

PATIENTS

Patients with cirrhosis with portal hypertension and controls paired for age and sex.

INTERVENTIONS

All patients were submitted to standard and image-enhanced colonoscopies, which were recorded in a coded video file and analyzed twice by a blinded endoscopist.

MAIN OUTCOME MEASUREMENTS

The prevalence of PHC.

RESULTS

A total of 51 patients with cirrhosis (55% male, mean age 59 years) and 51 healthy controls (43% male, mean age 61 years) were included. The top ranking colonoscopic findings were angiodysplasia-like lesions, nonspecific vascular pattern, red spots, and colorectal varices, all significantly more frequent in patients with cirrhosis compared with controls. PHC prevalence was 71% in patients with cirrhosis. For PHC, interobserver and intraobserver agreement (k values [standard error]) were 0.68 (0.09) and 0.63 (0.10), respectively. Intraobserver agreement for colonoscopic findings was satisfactory. PHC was not related to more severe liver disease or liver stiffness. Only 5 patients developed severe outcomes during follow-up.

LIMITATIONS

The exclusion of patients with cirrhosis without esophageal varices and the absence of an interobserver agreement analysis by double-blinded endoscopists.

CONCLUSION

PHC was highly prevalent in patients with cirrhosis, and its diagnostic agreement was satisfactory. PHC is not associated with relevant severe outcomes in a 12-month follow-up.