What is the treatment for gastrointestinal (GI) bleeding due to portal hypertensive gastropathy?

Treatment of GI Bleeding Due to Portal Hypertensive Gastropathy

Portal hypertensive gastropathy bleeding should be managed primarily with portal hypertension-lowering measures, including vasoactive therapy in the acute setting and beta-blockers for chronic management. 1

Acute Management Algorithm

1. Initial stabilization and medical management

   • Follow standard portal hypertensive bleeding protocols with:
     • Vasoactive drugs (terlipressin or octreotide) to reduce splanchnic blood flow 1, 2
     • Restrictive red blood cell transfusion strategy to avoid increasing portal pressure 1
     • Short course of prophylactic antibiotics 1

2. Acute pharmacological therapy

   • Octreotide: 100 μg IV bolus followed by 50 μg/hour continuous IV infusion 2
   • Continue for 24-48 hours to control active bleeding 2
   • If hemodynamically stable, introduce oral non-selective beta-blockers (NSBBs) 1, 3

3. Endoscopic management

   • Limited role in PHG bleeding compared to variceal bleeding 2
   • Argon plasma coagulation can be used for focal bleeding lesions 1, 2

Chronic Management and Prevention of Rebleeding

1. Pharmacological therapy

   • First-line: Non-selective beta-blockers 1, 3
     • Propranolol: Start at 40 mg/day orally in divided doses 2
     • Titrate dose to achieve resting heart rate of approximately 60 beats per minute 2
     • Target: 10-12% reduction in hepatic venous pressure gradient 3

2. Management of treatment failure

   • For patients who fail beta-blocker therapy or cannot tolerate it:
     • Transjugular intrahepatic portosystemic shunt (TIPS) is recommended 1, 2
     • TIPS reduces portal pressure and lessens the severity of PHG 1, 2

3. Adjunctive measures

   • Iron supplementation for chronic blood loss and anemia 1, 2
   • Address underlying liver disease and portal hypertension causes 3

Special Considerations

• Hemostatic abnormalities: In case of failure to control hemorrhage with portal hypertension-lowering drugs, correction of hemostasis should be considered on a case-by-case basis 1

• Monitoring: Regular endoscopic surveillance to assess PHG severity 1, 4

• Prognosis: While acute bleeding from PHG is infrequent, it can be severe with mortality risk 4

Important Caveats

• PHG is diagnosed endoscopically by mosaic-like pattern resembling 'snake-skin' with or without red spots 1, 5

• Avoid large volume transfusions which may paradoxically increase portal pressure and worsen bleeding 1, 3

• Unlike gastric antral vascular ectasia (GAVE), which may appear similar endoscopically, PHG responds to portal pressure reduction 2, 5

• PHG bleeding accounts for 2-12% of all GI bleeding episodes in cirrhotic patients 1

• The presence of esophageal varices and Child-Pugh class B or C are predictive factors for PHG development and progression 4