Portal hypertensive gastropathy and gastric antral vascular ectasia

Nelson Garcia, Arun J. Sanyal

Portal hypertensive gastropathy (PHG) causes both acute and chronic blood loss from the gastrointestinal tract in patients with portal hypertension. Gastric antral vascular ectasia (GAVE) is a distinct condition also associated with portal hypertension that can cause acute and chronic upper gastrointestinal blood loss. These conditions frequently, but not invariably, are diagnosed by upper endoscopy. Although they are fairly prevalent, only 15% to 20% of subjects experience symptomatic gastrointestinal blood loss. Acute gastrointestinal bleeding from PHG should first be treated with octreotide (100 mg bolus intravenously, followed by a 50 mg/h continuous intravenous infusion). If the bleeding does not stop or slow down appreciably within 24 to 48 hours, propranolol may be administered orally to those patients who are hemodynamically stable. Propranolol should be started at 40 mg/d orally in two divided doses. If the patient can tolerate the propranolol and is still bleeding, the dosage may be titrated up to the maximum tolerated amount. For those subjects who are unable to tolerate beta-blockers or continue to bleed despite beta-blocker therapy, transjugular intrahepatic portosystemic shunt (TIPS) is the next line of treatment. Portal decompressive surgery is reserved for those who are not candidates for TIPS and where the appropriate expertise is available. Prevention of chronic gastrointestinal blood loss from PHG should be attempted with beta-blockers, with the dosage titrated up to achieve a resting heart rate of approximately 60 beats per minute. In patients who do not respond to beta-blockers, a TIPS should be placed. The role of long-acting release octreotide in this setting is experimental. The primary treatment of actively bleeding GAVE as well as recurrent bleeding from GAVE is endoscopic ablation of the lesion using either argon plasma coagulation, neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, or heater probe. TIPS and beta-blockers are ineffective for the long-term prevention of recurrent bleeding from GAVE. For selected patients with severe recurrent bleeding or uncontrollable acute bleeding from GAVE, an antrectomy with Billroth I anastomosis may be considered.