Portal hypertensive gastropathy and gastric antral vascular ectasia
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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.
KeywordsPropranolol Octreotide Transjugular Intrahepatic Portosystemic Shunt Tranexamic Acid Main Drug Interaction
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References and Recommended Reading
- 2.Sarin SK, Shahi HM, Jain M, et al.: The natural history of portal hypertensive gastropathy: influence of variceal eradication. Am J Gastroenterol 2000, 95:2888–2893. This is a recent prospective study evaluating the natural history of PHG following endoscopic sclerotherapy of gastroesophageal varices.PubMedCrossRefGoogle Scholar
- 5.Spina G, Arcidiacono R, Bosch J, et al.: Gastric endoscopic features in portal hypertension: final report of a consensus conference, Milan, Italy, September 19, 1992. J Hepatol 1994, 21:461–467. This consensus conference report provides standardized endoscopic criteria by which to grade portal hypertensive gastropathy.PubMedCrossRefGoogle Scholar
- 38.Focke G, Seidl C, Grouls V: Treatment of watermelon stomach (GAVE syndrome) with endoscopic argon plasma coagulation (APC). A new therapy approach [in German]. Leber Magen Darm 1996, 26:254;257–254;259.Google Scholar
- 40.Katz PO, Salas L: Less frequent causes of upper gastrointestinal bleeding. Gastroenterology Clin North Am 1993, 22:875–889.Google Scholar