From the Guidelines
The management of portal venous gastropathy should focus on reducing portal pressure and treating any acute bleeding, with first-line treatment including non-selective beta-blockers such as propranolol or nadolol to reduce portal pressure, as recommended by the most recent study 1.
Key Management Strategies
- Reducing portal pressure is the primary goal in managing portal venous gastropathy, and this can be achieved through the use of non-selective beta-blockers such as propranolol (starting at 20mg twice daily and titrating up as tolerated) or nadolol (20-40mg daily) 1.
- For acute bleeding episodes, intravenous octreotide or terlipressin should be administered to reduce splanchnic blood flow, although the evidence for this is not as strong for portal hypertensive gastropathy as it is for varices 1.
- Endoscopic therapy has limited efficacy in portal gastropathy, unlike for varices, and is not recommended as a first-line treatment 1.
- In severe or refractory cases, transjugular intrahepatic portosystemic shunt (TIPS) procedure may be necessary to decompress the portal system, although this should be considered carefully due to the risks of hepatic encephalopathy and hepatic ischemia 1.
Additional Considerations
- Iron supplementation is often required to manage chronic blood loss anemia, and can be given orally or intravenously depending on the severity of iron depletion 1.
- The underlying liver disease should be treated concurrently, as improvement in liver function can reduce portal hypertension, and alcohol cessation is crucial for patients with alcoholic liver disease 1.
- Regular endoscopic surveillance every 6-12 months is recommended to monitor disease progression and response to therapy, although the optimal frequency and timing of surveillance are not well established 1.
From the Research
Management of Portal Venous Gastropathy
The management of portal venous gastropathy (also known as portal hypertensive gastropathy) involves several approaches, including:
- Portal-hypotensive pharmacological treatment, which is the mainstay of management for portal hypertensive gastropathy 2
- Endoscopic therapy, which is beneficial for gastric antral vascular ectasia 2
- Portacaval shunt, which has been shown to permanently stop bleeding in patients with severe portal hypertensive gastropathy 3
- Other treatment methods, such as transjugular intrahepatic portosystemic shunt (TIPS) or surgical approaches, which may be used to decrease portal pressure 4
Treatment Options
Treatment options for portal venous gastropathy depend on the severity of the condition and the presence of bleeding. Some treatment options include:
- Medications, such as nonselective β-blockers, to decrease portal pressure 4
- Endoscopic variceal ligation (EVL), endoscopic injection sclerotherapy (EIS), and tissue adhesive injection to obstruct gastroesophageal varices 4
- Radiological intervention, such as balloon-occluded retrograde transvenous obliteration (BRTO) 4
Underlying Mechanism
The underlying mechanism of portal hypertensive gastropathy is not fully understood, but it is thought to be related to portal hypertension and changes in the gastric mucosa. Studies have shown that there is no correlation between the presence or severity of portal hypertensive gastropathy and portal pressure, Child-Pugh classification, or systemic hemodynamics 5, 6. This suggests that other factors, such as local gastric mucosal factors or other underlying factors, may be involved in the physiopathology of portal hypertensive gastropathy.