What is the recommended treatment for portal hypertensive gastropathy?

Treatment of Portal Hypertensive Gastropathy

For portal hypertensive gastropathy causing chronic bleeding and anemia, initiate non-selective beta-blockers (propranolol or nadolol) combined with iron supplementation as first-line therapy, reserving TIPS for patients who remain transfusion-dependent despite optimal medical management. 1

First-Line Medical Management

Non-Selective Beta-Blockers (NSBBs)

• Start propranolol at 40 mg twice daily, titrating to 80 mg twice daily (or maximum tolerated dose) with the goal of reducing resting heart rate by 25% or to 55 bpm, whichever is lower. 2, 3
• Alternative agents include nadolol or long-acting propranolol 80 mg once daily to improve compliance. 2, 3
• NSBBs reduce portal pressure through decreased cardiac output and splanchnic vasoconstriction, addressing the underlying pathophysiology of PHG. 4, 5
• Monitor baseline heart rate and blood pressure before initiation and at each dose adjustment. 2

Iron Supplementation

• Begin with oral iron supplements initially to replenish iron stores in all patients with PHG-related iron deficiency anemia. 1
• Switch to intravenous iron if the patient does not tolerate oral iron, ferritin levels fail to improve after an adequate trial, or ongoing bleeding prevents adequate oral absorption. 1
• IV iron formulations requiring only 1-2 infusions are preferred over those requiring multiple infusions. 1

Critical Differentiation: PHG vs GAVE

It is essential to distinguish PHG from gastric antral vascular ectasia (GAVE), as their treatments differ fundamentally. 1

• PHG presents with a mosaic "snake-skin" pattern with or without red spots, typically in the proximal stomach (fundus/body). 3, 5
• GAVE shows characteristic red spots without background mosaic pattern, localized to the gastric antrum, often in linear distribution ("watermelon stomach"). 1, 3
• TIPS does not benefit GAVE and should not be used for bleeding solely from GAVE, though it may be considered when PHG co-exists. 1
• For GAVE, endoscopic therapy (argon plasma coagulation, endoscopic band ligation, or radiofrequency ablation) is the primary treatment. 1

Second-Line Therapy: TIPS

TIPS should be considered in patients with PHG requiring repeated transfusions despite adequate NSBB therapy and iron replacement. 1

Indications for TIPS in PHG

• Transfusion-dependent patients refractory to NSBBs and iron therapy. 1, 3
• Patients who cannot tolerate or have contraindications to NSBBs. 1
• TIPS improves PHG endoscopic appearance and reduces transfusion requirements in refractory cases. 1

TIPS Contraindications and Cautions

• Child-Pugh score >13 (salvage TIPS not recommended). 1
• Pre-existing hepatic encephalopathy. 2
• Severe cardiac or pulmonary failure. 2
• Active infection or bilirubin >50 μmol/L. 2

Expected Outcomes

• Approximately one-third of patients develop hepatic encephalopathy after TIPS, usually manageable with medical therapy. 2
• In severe encephalopathy cases, TIPS diameter reduction or occlusion may be necessary. 2

Management of Acute Bleeding from PHG (Rare)

For the uncommon scenario of acute hemorrhage from PHG, initiate vasoactive drugs immediately before endoscopy. 3, 6

• Octreotide: 100 mcg IV bolus, followed by 50 mcg/hour continuous infusion. 6
• Alternative: Terlipressin (if available), which has longer half-life and superior efficacy. 4, 3
• Once bleeding is controlled, transition to oral NSBB for long-term management. 3, 6
• Consider TIPS for patients who rebleed or continue bleeding despite adequate beta-blocker therapy. 3, 6

Monitoring and Follow-Up

• Assess hemoglobin, ferritin levels, and transfusion requirements every 2-3 months. 1
• Monitor for NSBB side effects including bradycardia, hypotension, and bronchospasm. 2
• Temporarily suspend NSBBs if systolic BP <90 mmHg or mean arterial pressure <65 mmHg. 4, 7
• Endoscopic surveillance to reassess PHG severity and rule out development of varices. 5

Common Pitfalls to Avoid

• Do not use NSBBs or TIPS for isolated GAVE bleeding—these interventions are ineffective and may cause harm. 1, 3, 6
• Avoid starting NSBBs in patients with refractory ascites and hypotension without careful monitoring. 4, 7
• Do not rely on endoscopic therapy (APC, laser) as primary treatment for PHG—while some studies show benefit when combined with NSBBs, the evidence is limited and endoscopic therapy plays a minimal role compared to GAVE. 3, 5, 8
• Ensure adequate trial of medical therapy before proceeding to TIPS, as the procedure carries significant risks including encephalopathy. 1, 2