What is portal hypertensive gastropathy in adults with a history of liver disease, such as cirrhosis?

What is Portal Hypertensive Gastropathy?

Portal hypertensive gastropathy (PHG) is a gastric mucosal abnormality that occurs in patients with portal hypertension, characterized by a distinctive "snake-skin appearance" or mosaic pattern on endoscopy, which can cause chronic gastrointestinal bleeding leading to iron-deficiency anemia and reduced quality of life. 1

Endoscopic Diagnosis and Classification

PHG is diagnosed exclusively by endoscopy when characteristic gastric mucosal changes are visualized in patients with portal hypertension 1:

• Mild PHG: Gastric mucosal changes showing a mosaic-like pattern resembling "snake-skin" without additional features 1, 2
• Severe PHG: Mosaic pattern plus red or dark brown viscous changes (red spots) on the gastric mucosa 1
• The lesions typically affect the gastric fundus and body, with a proximal distribution 3

Severe PHG causes more chronic bleeding than the mild form and is clinically more significant. 1

Clinical Presentation

The primary clinical manifestation of PHG is chronic gastrointestinal bleeding rather than acute hemorrhage 1, 4:

• Chronic blood loss leading to iron-deficiency anemia is the most common presentation 1, 4
• Patients often require repeated blood transfusions, significantly reducing quality of life 1, 4
• Acute bleeding from PHG is infrequent but can occur and may be severe 5
• One study found that during follow-up, 16 patients bled from PHG (9 acutely and 7 chronically), with one death from exsanguination 5

Pathophysiology and Associated Factors

The underlying mechanism involves portal hypertension causing gastric mucosal vascular changes 1:

• Portal hypertension is the key factor for PHG development, though the exact pathogenesis is not completely understood 2
• Histologically, PHG is characterized by dilation of mucosal and submucosal vessels in the stomach 6
• The presence of esophageal varices and Child-Pugh class B or C are independent predictors of PHG incidence 5
• Interestingly, research shows no direct correlation between the severity of PHG and the degree of portal pressure elevation (HVPG measurements), suggesting other local gastric mucosal factors may be involved 6

Natural History and Prevalence

PHG is extremely common in cirrhotic patients with portal hypertension 1, 5:

• Prevalence ranges from 76-93% in patients with cirrhosis, depending on diagnostic method used 6
• The incidence of new PHG is 3% at 1 year and 24% at 3 years in patients with mild portal hypertension 5
• Progression from mild to severe PHG occurs in 3% at 1 year and 14% at 3 years 5
• Severity of liver disease (Child-Pugh class) and presence of esophageal varices are the strongest predictors of both incidence and progression 5

Critical Distinction: PHG vs GAVE

PHG must be distinguished from gastric antral vascular ectasia (GAVE or "watermelon stomach"), as these are separate entities requiring different treatments 7, 3:

• GAVE shows red spots without a background mosaic pattern, typically in the gastric antrum with linear distribution 3
• PHG shows a mosaic pattern with or without red signs, with proximal (fundus/body) distribution 3
• Only 30% of GAVE patients have portal hypertension, and GAVE can occur independently of liver disease 1, 7
• GAVE involves fibrin thrombi and fibromuscular hyperplasia of the lamina propria, a distinct pathophysiology 1, 7
• Beta-blockers and TIPS do not reduce bleeding risk in GAVE and should not be used for this condition 3

Common Pitfalls

• Do not assume all gastric bleeding in cirrhotic patients is from varices—PHG is an important alternative source that requires different management 1, 4
• Do not confuse PHG with GAVE—the endoscopic appearance, anatomic distribution, and treatment approaches are fundamentally different 7, 3
• Do not rely solely on portal pressure measurements to predict PHG severity, as correlation is poor 6