Portal hypertensive gastropathy (PHG) is a condition in which the gastric mucosal area is subjected to friability. This condition leads to changes in gastric mucosa, which normally occurs due to portal hypertension. Treatment for PHG is usually done using endoscopy, where fiber-optic camera can be used to view the gastric mucosal area.
Complications of Portal Hypertension: Management Dilemmas
Medications are usually prescribed to stop the bleeding because of PHG. Medications are also suggested to treat PHG that occurs as a result of varices treatment. Treatment for PHG is suggested based on various factors such as symptoms, bleeding rate, and severity of the disease. Some of the medications and treatment for PHG are discussed below.
Argon Plasma Coagulation Technique
Argon plasma coagulation is a technique by which bleeding and abnormalities in gastric mucosa are treated through electro surgery approach. In this technique, hemostasis and coagulation are created in the bleeding lesion location of gastric mucosa through a jet of argon plasma, when a current of high frequency is applied to the bleeding tissue. Tissue penetration depth due to argon plasma jet is much limited (in the order of millimeter). It has been observed that the argon plasma coagulation technique had improved the hemoglobin levels and decreased the need for transfusion in patients affected with PHG.
Argon Plasma Coagulation Procedure
The whole argon plasma coagulation arrangement consists of a source of argon gas, high-frequency generator, and a probe. Optimum parameters to avoid the local perforation risks are 2.5 l/min of argon gas flow and electrical power output in the range of 60–90 W. Argon plasma coagulation procedure is carried out in all the lesions that are visible in the gastric mucosal area. Argon plasma jet is applied on the bleeding location for about 1–3 s. The time taken to complete the whole procedure is about 15–30 min. Formation of white coagulum in gastric mucosal bleeding site indicates the successful completion of the procedure. All the patients are subjected to pump inhibitor therapy to enhance the mucosal healing after the argon plasma coagulation. Improvement in hemoglobin levels, initial symptoms cessation, and decrease in the need for blood transfusions are the possible outcomes of argon plasma coagulation procedure.
Transjugular Intrahepatic Pportosystemic Shunt Technique
Transjugular intrahepatic portosystemic shunt technique (TIPS) is used to treat PHG by creating an artificial channel between portal vein and systemic vessels to cure portal hypertension. Generally, TIPS technique is performed using fluoroscopy to treat postal hypertensive gastropathy.
It has been observed that there is a drop in portal vein pressure after the TIPS procedure. The TIPS procedure significantly increases the blood flow to 55.6 ml/min/100 g in gastric mucosa. TIPS procedure for treating PHG does not have any impact on the function of liver. Improvement in PHG after TIPS procedure can be observed by the improvement in damaged gastrointestinal perfusion in patients affected with PHG. TIPS procedure led to complete recovery of hemorrhage due to severe PHG in patients with massive hematemesis.
Salvage Cryotherapy
In this method, PHG is treated by freezing and destroying the gastric mucosal tissue in the bleeding region using pressurized carbon dioxide. Initially, cryotherapy technique identifies vascular ecstasias all over the gastric mucosa, especially in antrum. Then, liquid nitrogen or pressurized carbon dioxide is used for ablating the lesions in gastric mucosal antrum. Successful cryotherapy is indicated by ablation in frozen and hyperemic tissues. This technique can be performed as a salvage procedure when compared to all other treatment methods for PHG.
Medications
Nonselective β-blockers (propranolol and nadolol)
Nonselective β-blockers are suggested for people with mild PHG. Nevertheless, prescription of nonselective β-blockers as a primary prophylaxis is still disputable for patients suffering from gastro mucosal bleeding due to PHG. Nonselective β-blockers are found to decrease long-term bleeding secondary to PHG.
The risk of occurrence of PHG post-esophageal variceal eradication is reduced when treated with propranolol. Generally, propranolol is suggested to control bleeding in gastro mucosa due to severe PHG. Occurrence of PHG is found to be less when propranolol is preferred over band ligation. Typically, 240-480 mg/d of propranolol will be prescribed to control acute bleeding due to PHG. The need for blood transfusion is comparatively less when propranolol is used to treat PHG.
Octreotide and Somatostatin
It has been observed that the portal blood flow, portal pressure, and gastric perfusion have been reduced, when PHG patients are treated with octreotide and somatostatin. The use of octreotide can remarkably reduce gastric mucosal vein cross-sectional area. Initial stage treatment for acute bleeding due to PHG is octreotide. Octreotide can remarkably control the bleeding rate when compared to omeprazole. Both somatostatin and octreotide can decrease portal pressure only for a short period of time.
Portal Hypertension Panel, Part 1: Medical Management
Further Reading