How often should a patient with extra‑hepatic portal vein obstruction, portal hypertension, and severe portal‑hypertensive gastropathy undergo upper gastrointestinal endoscopy?

Endoscopic Surveillance in EHPVO with Severe Portal Hypertensive Gastropathy

Patients with extrahepatic portal vein obstruction (EHPVO), portal hypertension, and severe portal hypertensive gastropathy should undergo upper gastrointestinal endoscopy every 6-12 months after initial variceal management, with the specific interval determined by the presence and grade of varices, ongoing bleeding risk, and response to therapy.

Initial Endoscopic Assessment and Management

• All patients with EHPVO and portal hypertension should undergo baseline screening endoscopy to assess for esophageal varices, gastric varices, and portal hypertensive gastropathy severity 1
• The EASL guidelines recommend managing portal hypertension in EHPVO according to the same principles as cirrhotic portal hypertension, including endoscopic surveillance protocols 1
• Beta-adrenergic blockade decreases bleeding risk in patients with large varices and improves survival in chronic portomesenteric venous obstruction 1

Surveillance Intervals Based on Variceal Status

After Variceal Eradication

• Following complete eradication of esophageal varices through endoscopic band ligation or sclerotherapy, the first surveillance endoscopy should occur at 3 months 2
• Subsequent surveillance should continue at 6-month intervals after the first year to monitor for variceal recurrence 2
• Esophageal varices recur in approximately 40% of EHPVO patients after eradication, necessitating ongoing surveillance 3

Patients with Persistent Small Varices

• If small varices persist despite therapy, annual endoscopy is appropriate, particularly given the non-cirrhotic nature of EHPVO where progression rates may differ from cirrhotic portal hypertension 1
• The combination of endoscopic surveillance with beta-blocker therapy provides optimal secondary prophylaxis 1

Special Considerations for Severe PHG in EHPVO

Gastropathy-Specific Monitoring

• Severe portal hypertensive gastropathy increases in both frequency (from 12% to 41%) and severity following variceal eradication in EHPVO patients 3
• This paradoxical worsening of PHG after sclerotherapy necessitates closer surveillance than in patients without severe gastropathy 3
• For patients with severe PHG and history of bleeding, endoscopy should be performed every 6 months to assess both mucosal changes and development of new varices 3

Gastric Variceal Evolution

• Secondary gastric varices develop in 28% of EHPVO patients after esophageal variceal treatment, with a shift from gastroesophageal varices type 1 (GOV1) to isolated gastric varices (IGV) 3
• GOV1 decreases while GOV2 and IGV increase significantly after sclerotherapy, requiring vigilant surveillance 3
• Rebleeding from gastric varices occurs in approximately 7% of cases, irrespective of variceal type 3

Algorithmic Approach to Surveillance Timing

High-Risk Features (any of the following):

• History of variceal bleeding within past year
• Severe PHG with prior bleeding episodes
• Development of secondary gastric varices (especially IGV)
• Recurrent varices after eradication
• Surveillance interval: Every 6 months 3, 2

Moderate-Risk Features:

• Severe PHG without recent bleeding
• Small persistent varices on beta-blockers
• Complete variceal eradication achieved
• Surveillance interval: Every 6-12 months 1, 2

Lower-Risk Features:

• No varices on initial screening
• Mild PHG only
• Successful surgical shunt with decompression
• Surveillance interval: Every 12 months 1

Critical Pitfalls to Avoid

• Do not assume EHPVO behaves identically to cirrhotic portal hypertension: While management principles are similar, the natural history differs, particularly regarding PHG progression after variceal therapy 4, 3
• Do not discontinue surveillance after variceal eradication: The 40% recurrence rate in EHPVO mandates lifelong surveillance 3
• Do not overlook gastric variceal evolution: The shift from GOV1 to more dangerous IGV patterns requires specific attention during each examination 3
• Do not rely solely on variceal status: Severe PHG itself can cause significant bleeding independent of varices, requiring assessment of mucosal changes at each endoscopy 5, 6

Therapeutic Implications During Surveillance

• Non-selective beta-blockers remain the mainstay for chronic bleeding prevention from both varices and severe PHG 1, 5
• Endoscopic band ligation is superior to sclerotherapy in pediatric EHPVO populations and should be the preferred modality when repeat intervention is needed 1
• If medical and endoscopic management fail, surgical portosystemic shunting (mesenterico-Rex shunt when feasible) or TIPS should be considered, as these definitively address the underlying portal hypertension 1