Pathogenesis of portal hypertensive gastropathy: a clinical and experimental review

The Impact of Partial Splenic Embolization on Portal Hypertensive Gastropathy in Cirrhotic Patients with Portal Hypertension

This study investigated the impact of partial splenic embolization (PSE) on portal hypertensive gastropathy (PHG). We retrospectively analyzed endoscopic findings and the portal venous system of 31 cirrhotic patients with PHG. The improved group was defined as the amelioration of PHG findings using the McCormack classification. Child–Pugh scores of the improved group (18 of 31 patients) were significantly lower compared with those of the non-improved group (p = 0.018). The changes in the diameters of the portal trunk and those of the spleno-portal junction and spleen hilum in the splenic vein of the improved group were significantly larger than those of the non-improved group (p = 0.007, p = 0.025, and p = 0.003, respectively). The changes in the diameters of the portal vein and splenic hilum of the splenic vein showed significant correlations with Child–Pugh score (r = 0.386, p = 0.039; r = 0.510, p = 0.004). In a multivariate analysis of baseline factors related to the improved group, Child–Pugh grade A was significantly associated with the improvement of PHG (odds ratio 6.875, p = 0.033). PSE could be useful for PHG, especially in patients with Child–Pugh grade A, at least in the short term.

p53 upregulated by HIF-1α promotes gastric mucosal epithelial cells apoptosis in portal hypertensive gastropathy

BACKGROUND

Portal hypertensive gastropathy (PHG) is a serious complication of liver cirrhosis and a potential cause of gastrointestinal bleeding. Mucosal apoptosis is an essential pathological feature of PHG. However, whether HIF-1α and p53 are involved in mucosal apoptosis and whether HIF-1α induces PHG by mediating p53 remains unclear.

METHODS

Gastric mucosal injury and apoptosis were examined in PHG patients and animal models. The mechanisms of HIF-1α- and p53-mediated apoptosis were analyzed. The GES-1 cell line was used to elucidate the underlying mechanisms using siRNA knockdown of HIF-1α and p53 in a hypoxic environment in vitro.

RESULTS

Epithelial apoptosis, HIF-1α, and p53 were markedly induced in the gastric mucosa of PHG. Apoptosis was attenuated in mice with HIF-1α- and p53-specific inhibitors. Apoptotic signaling factors were markedly induced in the gastric mucosa of PHG. Inhibition of p53 demonstrably attenuated the mucosal apoptosis; however, it did not affect HIF-1α expression. Conversely, targeted deletion of HIF-1α significantly inhibited p53 expression and attenuated the injury and p53-mediated apoptosis. Bax and Bcl-2 expression can be upregulated and downregulated by p53, respectively, to increasecleaved caspase-3 expression, which can be regulated by HIF-1α.

CONCLUSIONS

These results indicate that HIF-1α regulates the p53-induced mucosal epithelial apoptotic signaling pathway and that HIF-1α and p53 are potential therapeutic targets for PHG.

Role of the posterior mucosal defense barrier in portal hypertensive gastropathy

Portal hypertensive gastropathy (PHG) is a complication of cirrhotic or noncirrhotic portal hypertension. PHG is very important in the clinic because it can cause acute or even massive blood loss, and its treatment efficacy and prognosis are poor. Currently, the incidence of PHG in patients with cirrhosis is 20-80%, but its pathogenesis is complicated and poorly understood. Studies have shown that portal hypertension can cause changes in gastric mucosal microcirculation hemodynamics, leading to changes in gastric mucosal histology and function and thereby weakening the mucosal defense barrier. However, no specific drug treatment plans are currently available. This article reviews the current literature to further our understanding of the mechanism underlying PHG and the relationship between PHG and the posterior mucosal defense barrier and to explore new therapeutic targets.

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.

Comparison of Efficacy of Laparoscopic and Open Splenectomy Combined With Selective and Nonselective Pericardial Devascularization in Portal Hypertension Patients

BACKGROUND

Recent advances in laparoscopic techniques have demonstrated that laparoscopy is superior for managing portal hypertension. This study aimed to compare the efficacy of laparoscopic splenectomy plus selective pericardial devascularization (LSSD) and open splenectomy and nonselective pericardial devascularization (OSD) in patients with portal hypertension.

METHODS

A total of 127 patients with portal hypertension underwent either LSSD or OSD at Jingzhou Central Hospital from January 2014 to December 2016. A total of, 55 patients received LSSD, including 29 male and 26 female individuals (age, 56.0±11.6 y); 72 patients received OSD, including 45 male and 27 female individuals (age, 53.4±10.9 y). The parameters of operation and outcomes were measured and compared.

RESULTS

Intraoperative blood loss, postoperative complications, and hospital stay were significantly lower in LSSD group but operation time was significantly lower in OSD group. Postoperative Child-Pugh score was significantly lower in LSSD group than in OSD group.

CONCLUSIONS

LSSD is a safe and effective treatment for liver cirrhosis patients with portal hypertension.

Blood Ammonia Level Correlates with Severity of Cirrhotic Portal Hypertensive Gastropathy

Background

Portal hypertensive gastropathy (PHG) is a common anomaly with potential for bleeding found in portal hypertension. Blood ammonia levels correlate well with liver disease severity and existence of portosystemic shunts. Increased ammonia results in vasodilation and hepatic stellate cell activation causing and exacerbating portal hypertension.

Objective

To assess the relation of blood ammonia to the presence and severity of portal hypertensive gastropathy in cirrhosis.

Methods

This cross-sectional study included 381 cirrhotics undergoing screening for esophageal varices (EV) divided into a portal hypertensive gastropathy group (203 patients with EV and PHG), esophageal varix group (41 patients with EV but no PHG), and control group (137 patients with no EV or PHG). A full clinical examination, routine laboratory tests, abdominal ultrasonography, child score calculation, and blood ammonia measurement were performed for all patients.

Results

Blood ammonia, portal vein, splenic vein, and splenic longitudinal diameters were significantly higher and platelet counts lower in patients with EV and EV with PHG than controls. Patients having EV with PHG had significantly higher bilirubin and ammonia than those with EV but no PHG. Severe PHG was associated with significantly higher ammonia, EV grades, and superior location and a lower splenic longitudinal diameter than mild PHG. The PHG score showed a positive correlation with blood ammonia and a negative correlation with splenic longitudinal diameter.

Conclusions

Blood ammonia levels correlate with the presence, severity, and score of portal hypertensive gastropathy in cirrhosis suggesting a causal relationship and encouraging trials of ammonia-lowering treatments for the management of severe PHG with a tendency to bleed.

Retrospective Study to Compare Selective Decongestive Devascularization and Gastrosplenic Shunt versus Splenectomy with Pericardial Devascularization for the Treatment of Patients with Esophagogastric Varices Due to Cirrhotic Portal Hypertension

Background

For patients with esophagogastric varices secondary to portal hypertension due to liver cirrhosis, portosystemic shunts and devascularization have become the most commonly used treatment methods. We have developed a novel surgical approach for the treatment of patients with cirrhotic portal hypertension, selective decongestive devascularization, and shunt of the gastrosplenic region (SDDS-GSR). This aim of this study was to compare the efficacy and safety of SDDS-GSR with splenectomy with pericardial devascularization (SPD).

Material/Methods

A retrospective study was undertaken between 2006 and 2013 and included 110 patients with cirrhotic portal hypertension, 34 of whom underwent SDDS-GSR; 76 patients underwent SPD. Kaplan-Meier analysis was used to evaluate clinical outcomes, mortality, the incidence of re-bleeding, encephalopathy, and portal venous system thrombosis (PVST).

Results

Postoperatively portal venous pressure decreased by 20% in both groups. The long-term incidence of re-bleeding and PVST was significantly lower in the SDDS-GSR group compared with the SPD group (P=0.018 and P=0.039, respectively).

Conclusions

This preliminary retrospective study has shown that SDDS-GSR was an effective treatment for patients with esophagogastric varices secondary to portal hypertension that may be used as a first-line treatment to prevent variceal bleeding and lower the incidence of PVST.

Microwave ablation versus hepatic resection for the treatment of hepatocellular carcinoma and oesophageal variceal bleeding in cirrhotic patients

PURPOSE

The aim of this study was to compare the results of microwave ablation (MWA) and hepatic resection (HR) when combined with pericardial devascularisation plus splenectomy (PCDV) for the treatment of patients with cirrhosis complicated by small hepatocellular carcinoma (HCC) and oesophageal variceal bleeding (EVB).

MATERIALS AND METHODS

Between 2001 and 2013, 73 patients (median age 53.2 years, 67% male) with small HCC and concomitant EVB who underwent MWA or HR for HCC and PCDV for cirrhotic portal hypertension were selected retrospectively for inclusion in this study. The overall survival curves and recurrence-free survival curves were calculated using the Kaplan-Meier method and compared using log-rank tests. Multivariate analysis was performed using the Cox regression model.

RESULTS

The 1-, 3- and 5-year overall survival rates were 95.2%, 71.4% and 38.1% and 96.7%, 53.3% and 43.3% for the HR and MWA groups, respectively; these did not differ significantly between the two groups. However, patients in the HR group had more post-operative complications (52.3% vs. 13.7%; p = 0.002). Multivariate analysis identified albumin and bilirubin levels and tumour size to be statistically significant and independent prognostic factors for overall survival, while BCLC stage was associated with poor recurrence-free survival. Furthermore, albumin levels were shown to be an independent predictive factor for post-operative complications.

CONCLUSIONS

For patients with small HCC and concomitant EVB, MWA plus PCDV may reduce the incidence of post-operative complications relative to and provide similar therapeutic benefits as HR plus PCDV, especially for patients with low albumin levels.

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.

Portal hypertensive gastropathy and colopathy

Portal hypertensive gastropathy (PHG) and colopathy (PHC) are considered complications of portal hypertension. Both entities are clinically relevant because they may cause insidious blood loss or even acute massive gastrointestinal hemorrhage. Endoscopic evaluation is necessary for the diagnosis of PHG and PHC. The existence of different endoscopic criteria for PHG and PHC makes consensus difficult and results in a broad range of reported prevalence. Therapy targeted at reduction of portal pressure and mucosal blood flow has been used to treat acute bleeding; nonselective β-blockers are the most frequently used agents. Further studies are needed to clarify the natural history, pathogenesis, and treatment of PHG and PHC.

[Gastritis and gastropathy]

Alterations of the stomach mucosa in response to different adverse effects result in various morphological and clinical symptoms. Gastric mucosa alterations can be classified on the bases of diverse viewpoints. It makes this overview difficult, that identical toxic effects may cause different mucosal changes and different toxic agents may produce similar mucosal appearance. The more accurate understanding of the pathological processes which develop in the stomach mucosa needs reconsideration. The authors make an attempt to define gastritis and gastropathy in order to classify and present their features. Gastritis is a histological definition indicating mucosal inflammation. Acute gastritis is caused by infections. The two most important forms of chronic gastritis are metaplastic atrophic gastritis with an autoimmune origin and Helicobacter pylori inflammation. Gastropathy is the name of different structural alterations of the mucosa. Its most important feature is the paucity of inflammatory signs. Gastropathies can be divided into 4 categories based on the nature of the underlying pathological effect, on its morphological appearance and the way of the development. Differential diagnosis is an important pathological and clinical task because different treatment methods and prognosis.

PUMA mediates ER stress-induced apoptosis in portal hypertensive gastropathy

Mucosal apoptosis has been demonstrated to be an essential pathological feature in portal hypertensive gastropathy (PHG). p53-upregulated modulator of apoptosis (PUMA) was identified as a BH3-only Bcl-2 family protein that has an essential role in apoptosis induced by a variety of stimuli, including endoplasmic reticulum (ER) stress. However, whether PUMA is involved in mucosal apoptosis in PHG remains unclear, and whether PUMA induces PHG by mediating ER stress remains unknown. The aim of the study is to investigate whether PUMA is involved in PHG by mediating ER stress apoptotic signaling. To identify whether PUMA is involved in PHG by mediating ER stress, gastric mucosal injury and apoptosis were studied in both PHG patients and PHG animal models using PUMA knockout (PUMA-KO) and PUMA wild-type (PUMA-WT) mice. The induction of PUMA expression and ER stress signaling were investigated, and the mechanisms of PUMA-mediated apoptosis were analyzed. GES-1 and SGC7901 cell lines were used to further identify whether PUMA-mediated apoptosis was induced by ER stress in vitro. Epithelial apoptosis and PUMA were markedly induced in the gastric mucosa of PHG patients and mouse PHG models. ER stress had a potent role in the induction of PUMA and apoptosis in PHG models, and the apoptosis was obviously attenuated in PUMA-KO mice. Although the targeted deletion of PUMA did not affect ER stress, mitochondrial apoptotic signaling was downregulated in mice. Meanwhile, PUMA knockdown significantly ameliorated ER stress-induced mitochondria-dependent apoptosis in vitro. These results indicate that PUMA mediates ER stress-induced mucosal epithelial apoptosis through the mitochondrial apoptotic pathway in PHG, and that PUMA is a potentially therapeutic target for PHG.

Effect of Helicobacter pylori and its virulence factors on portal hypertensive gastropathy and interleukin (IL)-8, IL-10, and tumor necrosis factor-alpha levels

BACKGROUND/AIM

We aimed to assess the influence of Helicobacter pylori and its virulent factors, cytotoxin associated gene (cag) A and E, on portal hypertensive gastropathy (PHG) and the levels of interleukin (IL)-8, IL-10, and tumor necrosis factor-alpha (TNF-α).

PATIENTS AND METHODS

The patients with cirrhosis underwent screening endoscopy and the lesions related to PHG were graded. Biopsies were obtained for histology, and polymerase chain reaction (PCR) of H. pylori 16S rRNA, cagA, cagE, and tissue cytokine levels was carried out. Absent or mild PHG was compared with moderate to severe PHG.

RESULTS

One hundred and forty patients with cirrhosis were studied; males numbered 92 and the mean age of the patients was 50.3 ± 12.0 years, H. pylori positivity in 87 (62.1%) patients was associated with male gender (P = 0.032), younger age (P = 0.029), hepatitis D etiology (P = 0.005), higher serum albumin (0.000), lower Child Pugh score (P = 0.001), and lower portal vein diameter (P = 0.001). There was no significant difference in the levels of TNF-α and IL-8. However, a decrease in the anti-inflammatory cytokine IL-10 was noted with moderate to severe gastropathy. Four H. pylori strains were positive for both cagA and cagE, while four were positive for cagA only. All the four patients with both virulent factors had mild gastropathy only.

CONCLUSION

The presence of H. pylori infection neither affected the severity of PHG nor augmented the IL-8 and TNF-α levels. There was a decline of virulent H. pylori strains and IL-10 levels in patients with advanced PHG.

Two surgical procedures for esophagogastric variceal bleeding in patients with portal hypertension

AIM: To determine the clinical value of a splenorenal shunt plus pericardial devascularization (PCVD) in portal hypertension (PHT) patients with variceal bleeding.

METHODS: From January 2008 to November 2012, 290 patients with cirrhotic portal hypertension were treated surgically in our department for the prevention of gastroesophageal variceal bleeding: 207 patients received a routine PCVD procedure (PCVD group), and 83 patients received a PCVD plus a splenorenal shunt procedure (combined group). Changes in hemodynamic parameters, rebleeding, encephalopathy, portal vein thrombosis, and mortality were analyzed.

RESULTS: The free portal pressure decreased to 21.43 ± 4.35 mmHg in the combined group compared with 24.61 ± 5.42 mmHg in the PCVD group (P < 0.05). The changes in hemodynamic parameters were more significant in the combined group (P < 0.05). The long-term rebleeding rate was 7.22% in the combined group, which was lower than that in the PCVD group (14.93%), (P < 0.05).

CONCLUSION: Devascularization plus splenorenal shunt is an effective and safe strategy to control esophagogastric variceal bleeding in PHT. It should be recommended as a first-line treatment for preventing bleeding in PHT patients when surgical interventions are considered.

Increased oxidative stress may lead to impaired adaptive cytoprotection in the gastric mucosa of portal hypertensive rat

BACKGROUND AND AIMS

In the gastric mucosa of portal hypertensive rats, adaptive cytoprotection against ethanol-induced damage is impaired. The aim of this study was to determine relation between impaired adaptive cytoprotection and oxidative stress.

METHODS

Portal hypertension was produced in male Sprague-Dawley rats by inducing staged portal vein occlusion. Oxidative stress levels were evaluated by measuring malondialdehyde and nitrotyrosine levels in the rat gastric mucosa with or without 10% ethanol pretreatment. Inhibition of oxidative stress by an anti-oxidant agent was estimated, and glutathione levels were also measured. Adaptive cytoprotection to 70% ethanol treatment was evaluated by measuring the gastric mucosal injury index in the presence or absence of the anti-oxidant.

RESULTS

The portal hypertensive gastric mucosa pretreated with 10% ethanol had significantly higher oxidative stress levels than the mucosa not pretreated with 10% ethanol. However, the sham-operated gastric mucosa pretreated with 10% ethanol had significantly lower oxidative stress levels than the mucosa not pretreated with 10% ethanol. Pretreatment with 10% ethanol increased glutathione levels in the sham-operated but not in the portal hypertensive gastric mucosa. Administration of the anti-oxidant agent prior to 10% ethanol pretreatment significantly reduced oxidative stress levels, increased glutathione levels, and decreased the injury index in response to 70% ethanol in the portal hypertensive gastric mucosa.

CONCLUSION

Increased oxidative stress may lead to impaired adaptive cytoprotection in the gastric mucosa of portal hypertensive rats, probably through damage to the system of endogenous anti-oxidant production.

Loss of parietal cell superoxide dismutase leads to gastric oxidative stress and increased injury susceptibility in mice

Mitochondrial superoxide dismutase (SOD2) prevents accumulation of the superoxide that arises as a consequence of oxidative phosphorylation. However, SOD2 is a target of oxidative/nitrosative inactivation, and reduced SOD2 activity has been demonstrated to contribute to portal hypertensive gastropathy. We investigated the consequences of gastric parietal cell-specific SOD2 deficiency on mitochondrial function and gastric injury susceptibility. Mice expressing Cre recombinase under control of the parietal cell Atpase4b gene promoter were crossed with mice harboring loxP sequences flanking the sod2 gene (SOD2 floxed mice). Cre-positive mice and Cre-negative littermates (controls) were used in studies of SOD2 expression, parietal cell function (ATP synthesis, acid secretion, and mitochondrial enzymatic activity), increased oxidative/nitrosative stress, and gastric susceptibility to acute injury. Parietal cell SOD2 deficiency was accompanied by a 20% (P < 0.05) reduction in total gastric SOD activity and a 93% (P < 0.001) reduction in gastric SOD2 activity. In SOD2-deficient mice, mitochondrial aconitase and ATP synthase activities were impaired by 36% (P < 0.0001) and 44% (P < 0.005), respectively. Gastric tissue ATP content was reduced by 34% (P < 0.002). Basal acid secretion and peak secretagogue (histamine)-induced acid secretion were reduced by 43% (P < 0.0001) and 40% (P < 0.0005), respectively. There was a fourfold (P < 0.02) increase in gastric mucosal apoptosis and 41% (P < 0.001) greater alcohol-induced gastric damage in the parietal cell SOD2-deficient mice. Our findings indicate that loss of parietal cell SOD2 leads to mitochondrial dysfunction, resulting in perturbed energy metabolism, impaired parietal cell function, and increased gastric mucosal oxidative stress. These alterations render the gastric mucosa significantly more susceptible to acute injury.

Clinical, laboratory, and hemodynamic parameters in portal hypertensive gastropathy: a study of 254 cirrhotics

BACKGROUND

Portal hypertensive gastropathy (PHG) is the most common gastric mucosal injury in patients with liver cirrhosis. It is a cause of both acute and chronic upper gastrointestinal bleeding even in the absence of esophageal or gastric varices. The pathogenesis of PHG is unclear. It is not known whether PHG correlates more with portal hypertension or with liver dysfunction. It is also not clear whether altered vascular hemodynamics occurring in PHG is purely a local phenomenon of the stomach or is it a part of a generalized vascular abnormality of cirrhosis and portal hypertension.

AIM

In the first part of our study, we aimed to assess any correlation of various clinical and laboratory parameters relating to portal hypertension and liver dysfunction with the presence or absence of PHG. In the second part of our study we examined whether systemic and pulmonary hemodynamics is significantly altered in patients with PHG.

PATIENTS AND METHODS

In this retrospective study, the records of consecutive cirrhotic patients who had undergone complete portal, systemic, and pulmonary hemodynamic assessments were analyzed. We excluded patients who had had endoscopic variceal ligation, endoscopic sclerotherapy, cyanoacrylate glue injection or surgery for portal hypertension, patients on beta-blockers, and patients with gastric antral vascular ectasia. Clinical, laboratory, and hemodynamic parameters were compared between patients with and without PHG.

RESULTS

Two hundred and fifty-four patients were included in the study (mean age 44.3+/-12.6 y, 82% males). One hundred and three (41%) patients had a history of upper gastrointestinal bleeding. Alcohol, hepatitis B, and cryptogeny were the most common etiologies (27% each). One hundred and forty (55%) patients had PHG. Variables significantly associated with PHG on univariate analysis were history of gastrointestinal bleed, ascites, high bilirubin, deranged prothrombin time, higher variceal grade, high Child-Pugh score, and high hepatic venous pressure gradient. However, on multivariate analysis only Child-Pugh class C, large variceal size, and hepatic venous pressure gradient greater than 12 mm Hg were independently associated with the presence of PHG. Patients with PHG were significantly more vasodilated as indicated by the high mean cardiac index (5.3+/-2.3 vs. 4.6+/-1.9 L/min/m, P=0.012), mean cardiac output (8.9+/-4.0 vs. 7.6+/-3.2 L/min, P=0.004), low median systemic vascular resistance [869 (252-2651) vs. 974 (403-2590) dyn.s/cm, P=0.012], and low median pulmonary vascular resistance [51 (6-226) vs. 63 (6-512) dyn.s/cm, P=0.003].

CONCLUSIONS

PHG is more often associated with advanced portal hypertension and advanced liver failure. The presence of PHG also indicates the existence of an additional vasodilation to already existent hemodynamic anomalies seen in portal hypertension as evidenced by a higher cardiac index and output and lower systemic and pulmonary resistance compared with patients without PHG. Thus, PHG is not merely a local phenomenon in gastric mucosa but also a severe manifestation of generalized vascular alterations of cirrhosis and portal hypertension.

Effects of modified splenocaval shunt plus devascularization on esophagogastric variceal bleeding: a comparative study of this treatment and devascularization only in cirrhotic portal hypertension

BACKGROUND

Pericardial devascularization (PCDV) and portosystemic shunt were reported to have favorable results for the management of portal hypertension in cirrhotic patients in China and the West, respectively. This study was undertaken to investigate the effects of a modified proximal splenocaval shunt plus PCDV on variceal bleeding in patients with portal hypertension.

METHODS

From January 1997 to December 2007, 168 patients with portal hypertension of cirrhotic origin received an operation for gastroesophageal variceal bleeding. Of these, 90 patients received a splenocaval shunt plus a PCDV procedure (Combined Group) and the other 78 patients received a PCDV procedure only (PCDV Group). The procedure-related morbidity and mortality, rebleeding, encephalopathy, and survival rates were analyzed.

RESULTS

Postoperative mortality was 3.3% in the combined group and 5.1% in the PCDV group (P > 0.05). Overall morbidity was 13.3% in the combined group and 15.4% in the PCDV group (P > 0.05). The rate for rebleeding, including variceal bleeding and gastropathy, was 5.1% in the combined group, which was significantly lower than that in the PCDV group, at 16.7% (P < 0.05). The incidence of encephalopathy was 6.63% in the combined group and 6.67% in the PCDV group (P > 0.05). The 1-, 3-, 5- and 10-year survival rates were 97.4, 91.7, 80.0, and 60.0% in the combined group and 96.7, 83.3, 73.3, and 53.3% in the PCDV group (P > 0.05).

CONCLUSIONS

The modified splenocaval shunt plus PCDV is a safe and effective procedure for the long-term control of variceal bleeding; the procedure may not only maintain the portal flow to the liver, but may also protect the liver function in cirrhotic patients. The better clinical outcome means that the procedure may be one of the best choices for treating portal hypertension of cirrhotic origin.

Effect of early propranolol administration on portal hypertensive gastropathy in cirrhotic rats

AIM

To investigate any protective effect of early propranolol administration in the development of portal hypertensive gastropathy in cirrhotic rats.

METHODS

For the development of liver cirrhosis and portal hypertensive gastropathy, 60 rats underwent ligation of the left adrenal vein and complete devascularization of the left renal vein, followed by phenobarbital and carbon tetrachloride (CCl(4)) administration. After two weeks of CCl(4) administration, the rats were randomly separated into two groups. In group A, propranolol was continuously administered intragastrically throughout the study, whereas in group B normal saline (placebo) was administered instead. Hemodynamic studies and vascular morphometric analysis of gastric sections were performed after complete induction of cirrhosis.

RESULTS

Vascular morphometric studies showed higher numbers of vessels in all mucosal layers in the control group. Statistical analysis revealed a significantly higher total vascular surface in the control group compared to the propranolol group, but with no statistically significant difference between the mean vascular surfaces between the groups. Our study clearly shows that the increased mucosal blood flow is manifested by a marked increase of vessel count.

CONCLUSION

Early propranolol's administration in portal hypertensive cirrhotic rats seems to prevent intense gastric vascular congestion that characterizes portal hypertensive gastropathy.

Underlying mechanism of portal hypertensive gastropathy in cirrhosis: a hemodynamic and morphological approach

BACKGROUND AND AIM

Portal hypertensive gastropathy (PHG) is an important cause of bleeding in patients with cirrhosis associated with portal hypertension. Histologically, the condition is characterized by dilation of the mucosal and submucosal vessels of the stomach; however, its mechanisms remain unclear. The aim of the present cross-sectional study was to evaluate the role of portal and systemic hemodynamic features, humoral factors and hepatocellular function in the development and severity of PHG in patients with cirrhosis.

METHODS

Forty-six patients with cirrhosis of different etiologies underwent endoscopy. Portal hypertension was evaluated by hepatic venous pressure gradient (HVPG). The gastric mucosa was analyzed using two diagnostic methods: endoscopy according to the McCormack criteria and histological by histomorphometric analysis.

RESULTS

The prevalence of PHG according to the endoscopic and histomorphometric methods was 93.4% and 76.1%, respectively. There were no statistically significant differences in HVPG measurements between the patients with mild (16.0 +/- 5.9 mmHg) and severe PHG (16.9 +/- 6.5 mmHg; P = 0.80) or between patients who did not have (15.2 +/- 8.0 mmHg) and those who had PHG (16.3 +/- 5.7 mmHg). No correlation was found between the presence or severity of PHG and systemic vascular resistance index (P = 0.53 and 0.34, respectively), Child-Pugh classification (P = 0.73 and 0.78, respectively) or glucagon levels (P = 0.59 and 0.62, respectively).

CONCLUSIONS

The present data show no correlation between the presence or the severity of PHG and portal pressure, Child-Pugh classification or systemic hemodynamics, suggesting that other factors may be involved in the physiopathology of PHG, such as local gastric mucosal factors or other underlying factors.

Effect of laparoscopic splenectomy on portal hypertensive gastropathy in cirrhotic patients with portal hypertension

AIM

This study investigated the relationship between portal hypertensive gastropathy (PHG) and splenomegaly, and the effect of laparoscopic splenectomy on PHG in cirrhotic patients with portal hypertension.

METHODS

Seventy patients with liver cirrhosis and portal hypertension were prospectively studied. Indication for laparoscopic splenectomy was bleeding tendency in 10 patients, induction of interferon in 45, treatment of hepatocellular carcinoma in seven, and treatment for endoscopic injection sclerotherapy-resistant esophagogastric varices in eight. The severity of PHG was classified into none, mild, or severe according to the classification by McCormack et al. The severity of liver disease was classified using the Child-Pugh score. All patients underwent upper gastrointestinal endoscopy before and 1 month after the operation.

RESULTS

The prevalence of PHG was significantly correlated with the severity of liver disease using the Child-Pugh score. The severity of PHG was significantly correlated with the resected spleen volume. One month after the operation, PHG was improved in 16 of 17 patients with severe PHG and in 12 of 32 with mild PHG. The Child-Pugh score showed a significant improvement (6.8 +/- 1.4 to 6.2 +/- 1.2) at 3 months after laparoscopic splenectomy (P < 0.0001).

CONCLUSIONS

PHG may be associated with splenomegaly, and laparoscopic splenectomy may have a beneficial effect on PHG, at least for a short time.

Increased heat-shock protein 90 expression contributes to impaired adaptive cytoprotection in the gastric mucosa of portal hypertensive rats

BACKGROUND AND AIMS

Portal hypertensive (PHT) gastropathy results in an increased susceptibility to damage. Adaptive cytoprotection against ethanol-induced damage is impaired in the gastric mucosa of rats with portal hypertension. Excessive nitric oxide (NO) production occurs in portal hypertension and is mediated in part via heat-shock protein (Hsp)90 production. The aim of this study was to investigate the relation between adaptive cytoprotection after exposure to ethanol and gastric expression of Hsp90 in PHT rats.

METHODS

Portal hypertension was induced in rats by staged portal vein occlusion. Adaptive cytoprotection to 70% ethanol was evaluated by assessing the injury index of the gastric mucosa with or without pretreatment with 10% ethanol. Expression of Hsp90 mRNA was evaluated by real-time polymerase chain reaction, and expression of Hsp90 protein was evaluated by western blotting. The effect of Hsp90 inhibition in PHT rats was evaluated by administration of geldanamycin.

RESULTS

Gastric Hsp90 mRNA expression in PHT rats was significantly less than that in sham-operated (SO) controls. However, after 10% ethanol pretreatment, Hsp90 mRNA expression was significantly greater in PHT rats than in SO controls. In PHT rats, gastric Hsp90 protein expression after 10% ethanol pretreatment was significantly greater than that without the pretreatment. However, the pretreatment had no effect on the injury index compared to SO rats. Administration of geldanamycin prior to 10% ethanol pretreatment significantly decreased the injury index in response to 70% ethanol in the PHT rats.

CONCLUSIONS

These results show that 10% ethanol pretreatment markedly increases gastric Hsp90 expression in PHT rats. Excessive production of Hsp90 may contribute impaired adaptive cytoprotection.

Blood ammonia levels in liver cirrhosis: a clue for the presence of portosystemic collateral veins

BACKGROUND

Portal hypertension leads to the formation of portosystemic collateral veins in liver cirrhosis. The resulting shunting is responsible for the development of portosystemic encephalopathy. Although ammonia plays a certain role in determining portosystemic encephalopathy, the venous ammonia level has not been found to correlate with the presence or severity of this entity. So, it has become partially obsolete. Realizing the need for non-invasive markers mirroring the presence of esophageal varices in order to reduce the number of endoscopy screening, we came back to determine whether there was a correlation between blood ammonia concentrations and the detection of portosystemic collateral veins, also evaluating splenomegaly, hypersplenism (thrombocytopenia) and the severity of liver cirrhosis.

METHODS

One hundred and fifty three consecutive patients with hepatic cirrhosis of various etiologies were recruited to participate in endoscopic and ultrasonography screening for the presence of portosystemic collaterals mostly esophageal varices, but also portal hypertensive gastropathy and large spontaneous shunts.

RESULTS

Based on Child-Pugh classification, the median level of blood ammonia was 45 mcM/L in 64 patients belonging to class A, 66 mcM/L in 66 patients of class B and 108 mcM/L in 23 patients of class C respectively (p < 0.001).The grade of esophageal varices was concordant with venous ammonia levels (rho 0.43, p < 0.001). The best area under the curve was given by ammonia concentrations, i, e., 0.78, when comparing areas of ammonia levels, platelet count and spleen longitudinal diameter at ultrasonography. Ammonia levels predicted hepatic decompensation and ascites presence (Odds Ratio 1.018, p < 0.001).

CONCLUSION

Identifying cirrhotic patients with high blood ammonia concentrations could be clinically useful, as high levels would lead to suspicion of being in presence of collaterals, in clinical practice of esophageal varices, and pinpoint those patients requiring closer follow-up and endoscopic screening.

Portal hypertensive gastropathy in chronic hepatitis C patients with bridging fibrosis and compensated cirrhosis: results from the HALT-C trial

OBJECTIVES

The clinical significance of portal hypertensive gastropathy (PHG) in patients with compensated liver disease is not well established. The aim of this study was to determine the prevalence and correlates of PHG in a large cohort of patients with chronic hepatitis C virus (HCV) infection and bridging fibrosis/compensated cirrhosis entering the randomized phase of the Hepatitis C Antiviral Long-term Treatment against Cirrhosis trial (HALT-C).

METHODS

The presence and severity of PHG in 1,016 HCV patients with no prior history of gastrointestinal bleeding was determined at surveillance endoscopy using the New Italian Endoscopy Club criteria.

RESULTS

Overall, 37% of HALT-C patients had PHG with 34% having mild and 3% with severe changes. The mucosal mosaic pattern was identified in 33%, red marks in 15%, and gastric antral vascular ectasia (GAVE) features in only 3%. Independent correlates of PHG included biochemical markers of liver disease severity (lower serum albumin, higher bilirubin), portal hypertension (lower platelet count), insulin resistance (higher glucose), and non-African American race. Independent correlates of GAVE included a history of smoking, nonsteroidal anti-inflammatory drugs (NSAIDs) use within the past year, and higher serum bilirubin and glucose levels. There was a strong positive association between the presence of PHG and esophageal varices (p < 0.0001).

CONCLUSIONS

PHG is associated with the histological and biochemical severity of liver disease in patients with HCV and advanced fibrosis but is mild in most patients. The clinical relevance of these findings will be further explored during the randomized phase of the HALT-C study.

Clinical analysis of surgical treatment of portal hypertension

AIM: To review the experience in surgery for 508 patients with portal hypertension and to explore the selection of reasonable operation under different conditions.

METHODS: The data of 508 patients with portal hypertension treated surgically in 1991-2001 in our centers were analyzed. Of the 508 patients, 256 were treated with portaazygous devascularization (PAD), 167 with portasystemic shunt (PSS), 62 with selective shunt (SS), 11 with combined portasystemic shunt and portaazygous devascularization (PSS+PAD), 9 with liver transplantation (LT), 3 with union operation for hepatic carcinoma and portal hypertension (HCC+PH).

RESULTS: In the 167 patients treated with PSS, free portal pressure (FPP) was significantly higher in the patients with a longer diameter of the anastomotic stoma than in those with a shorter diameter before the operation (P<0.01). After the operation, FPP in the former patients markedly decreased compared to the latter ones (P<0.01). The incidence rate of hemorrhage in patients treated with PAD, PSS, SS, PSS+PAD, and HCC+PH was 21.09% (54/256), 13.77 (23/167), 11.29 (7/62), 36.36% (4/11), and 100% (3/3), respectively. The incidence rate of hepatic encephalopathy was 3.91% (10/256), 9.58% (16/167), 4.84% (3/62), 9.09% (1/11), and 100% (3/3), respectively while the operative mortality was 5.49% (15/256), 4.22% (7/167), 4.84% (3/62), 9.09% (1/11), and 66.67% (2/3) respectively. The operative mortality of liver transplantation was 22.22% (2/9).

CONCLUSION: Five kinds of operation in surgical treatment of portal hypertension have their advantages and disadvantages. Therefore, the selection of operation should be based on the actual needs of the patients.

Quercetin prevents oxidative stress and NF-kappaB activation in gastric mucosa of portal hypertensive rats

The present study was designed to investigate the effects of quercetin on oxidative stress and activation of nuclear factor kappa B (NF-kappaB) in an experimental model of portal hypertensive gastropathy induced by partial portal vein ligation (PPVL). Portal pressure was significantly elevated in PPVL rats. Transaminase and alkaline phosphatase activities were not significantly modified, indicating absence of liver injury. Histological analysis of gastric sections showed a lost of normal architecture, with edema and vasodilatation. The cytosolic concentration of thiobarbituric acid reactive substances and the lipoperoxidation measurement by chemiluminiscence were significantly increased. Superoxide dismutase activity in gastric mucosa was significantly reduced. Portal hypertensive gastropathy induced a marked activation of NF-kappaB, accompanied by a decrease in IkappaB protein levels and a significant induction of nitric oxide synthase (iNOS) protein. Administration of quercetin markedly alleviated histological abnormalities and inhibited oxidative stress and NF-kappaB activation. IkappaB decrease and induction of iNOS protein were partially prevented by quercetin. Quercetin treatment, by abolishing the NF-kappaB signal transduction pathway, may block the production of noxious mediators involved in the pathogenesis of portal hypertensive gastropathy.

Protective effects of endothelin-1 antibody on stress induced lesion of gastric mucosa in rats

AIM

To explore the protective effects of endothelin-1 antibody (ET-1Ab) on acute gastric mucosa lesions induced by stress in rats.

METHODS

Stress ulcer induced by cold-restraint-stress(CRS) was used as model in this study, different dose ET-1Ab were administered by left femoral vein prior to stress so as to observe the effects of the drug on ET-1 levels in plasma and gastric mucosa, gastric mucosa blood flow(GMBF)and ulcer index(UI) of CRS rats.

RESULTS

(1) Compared with the normal control group, ET-1 levels of plasma and gastric mucosa and UI were increased significantly in the stress groups (116.2±4.7 mv and 125.1±4.2 mv vs 49.1±9.7 mv, 113.8±9.3 mv and 122.9±19.6 mv vs 52.3±10.3 mv, 28.6±1.85 mv and 51.2±5.93 mv vs 0, P<0.01), while GMBF were decreased markedly in stress groups (227.8±13.5 mv and 150.8±11.5 mv vs 405.8±23.3 mv, P<0.01).There was significantly positive correlation between ET-1 and UI (r = 0.96, P<0.01), and significantly negative correlation between ET-1 and GMBF(r = -0.91, P<0.01). (2) However, compared with the single-stress groups, ET-1 levels of plasma and gastric mucosa and UI were decreased significantly in ET-1Ab-stress groups (69.2±7.3 mv vs 116.2±24.7 mv, 80.6±12.3 mv vs 125.1±24.2 mv, 58.5±6.3 mv vs 113.8±29.3 mv, 68.9±9.6 mvvs 122.9±19.6 mv, 13.2±2.05 mv vs 28.6±1.85 mv, 25.8±3.62 mv vs 51.2±5.93 mv, P<0.01), GMBF were increased dramatically (329.8±16.3 mv vs 227.8±13.5 mv, 251.9±11.3 mv vs 150.8±1.5 mv, P<0.01), ET-1Ab can dose-dependently reduce levels of the ET-1 and UI, and improve GMBF significantly in cold-restraint-stress.

CONCLUSION

In the course of CRS-induced ulcers, endogenous ET-1 levels of plasma and gastric mucosa were increased significantly, and there were close relationship between ET-1 levels and UI. The increased ET-1 may involve in the pathogenesis of CRS-induced ulcers in rats by its vasoconstriction and marked reduction of GMBF. ET-1Ab can dose-dependently attenuate the degree of gastric mucosa lesions induced by CRS significantly. So it may have therapeutic effect for SU.

Portal Hypertensive gastropathy

Portal hypertensive gastropathy (PHG), a term used to describe the endoscopic appearance of gastric mucosa with a characteristic mosaic-like pattern with or without red spots, is a common finding in patients with portal hypertension. Current classification systems that describe the severity of PHG have many limitations, but it appears that simple grading systems have better inter- and intraobserver agreement. The wide variation in the reported prevalence of PHG is probably related to selection bias, absence of uniform criteria and classification, and more importantly, the differences in inter- and intraobserver variation. Pathogenesis of PHG is not clearly defined, but there is a very close relationship between portal hypertension and development of PHG. GAVE is a separate entity from PHG, but patients with severe PHG may have a GAVE-like appearance in the gastric antrum. Acute bleeding from PHG, seen usually in the presence of severe PHG, is often mild and self-limiting. Currently, the only treatment that could be recommended for prophylaxis of bleeding from PHG is nonselective B-blockers.