portal hypertensive gastropathy
Esophageal Varices

Video Endoscopic Sequence 1 of 5.

Esophageal Varices.

This endoscopic sequence is taken with magnifying
endoscope and aimed dedicated for portal hypertensive
gastropathy.

Portal hypertensive gastropathy is a potential cause of bleeding in patients with liver cirrhosis. Studies on its natural history have often included patients submitted to endoscopic or pharmacological treatment for portal hypertension

For more endoscopic details download the video clips by clicking on the endoscopic images, wait to be downloaded complete then press Alt and Enter; thus you can observe the video in full screen.

All endoscopic images shown in this Atlas contain
video clips.









 

portal hypertensive gastropathy

Video Endoscopic Sequence 2 of 5.

Endoscopic appearance of portal hypertensive gastropathy

This a 65-year-old man with cirrhosis.

Note the characteristic snakeskin appearance of the gastric mucosa.

Another variant of portal hypertension is portal
hypertensive gastropathy. It affects to 50 percent of
patients with portal hypertension. These patients have
dilated arterioles and venules (small veins). This
abnormality is seen usually in the fundus and cardia of the
stomach (approximately 2/3 of the stomach). It is rarely
seen in the antrum (last 1/3) of the stomach. It appears to
have a "snake skin " or "reticulated" appearance.

 

portal

Video Endoscopic Sequence 3 of 5.

The image and the video clip display a portal
hypertensive gastropathy using a magnifying endoscope.

Long-term treatment of portal gastropathy and gastric
varices is with beta-blockers. They usually take the form of
propranolol, a nonselective beta-blocker.
These medications allow the pressure within the veins to be
decreased, thus reducing the chance that bleeding will
occur. Increased incidence of portal hypertensive
gastropathy is noted in patients who undergo sclerotherapy
for esophageal varices in the past.

The natural history of portal hypertensive gastropathy is significantly influenced by the severity of liver disease and severity of portal hypertension. Acute bleeding from portal hypertensive gastropathy is infrequent but may be severe.

 

portal hypertensive gastropathy

Video Endoscopic Sequence 4 of 5.

Bleeding from portal hypertensive gastropathy accounts for
2.3% of bleeding episodes in cirrhosis. Although serious
bleeding from these sources is uncommon.

Portal hypertensive gastropathy (PHG) is an important cause of bleeding in patients with cirrhosis associated with portal hypertension. Histologically, the condition is characterized by dilation of the mucosal and submucosal vessels of the stomach; however, its mechanisms remain unclear. The aim of the present cross-sectional study was to evaluate the role of portal and systemic hemodynamic features, humoral factors and hepatocellular function in the development and severity of PHG in patients with cirrhosis.


Endoscopic Image of Portal hypertensive gastropathy

Video Endoscopic Sequence 5 of 5.

Endoscopic Image of Portal hypertensive gastropathy

Portal hypertensive gastropathy (PHG) is the most common
gastric mucosal injury to patients with liver cirrhosis. The
main histological change is that blood vessels in the mucosa
and submucosa become dilated and twisted, and the vessel
wall become thickened. In fact, PHG is the major factor in
patients with liver cirrhosis who were accompanied with
upper gastrointestinal hemorrhage. Therefore, to prevent
and cure PHG is particularly important in preventing upper
gastrointestinal hemorrhage in patients with liver cirrhosis.
Hp infection is closely related to peptic ulcer, chronic
gastritis, and gastric cancer; but the relationship between
Hp infection and PHG is not clear.

Peptic Ulcer and Liver Cirrhosis.

Video Endoscopic Sequence 1 of 5.

Peptic Ulcer and Liver Cirrhosis.

This 84 year-old male who was hospitalized due a urosepsis
and melena one week before underwent a Transurethral
prostatectomy, no previous medical history of liver
cirrhosis was know.

Peptic ulcer has been reported with increased frequency in
patients with liver cirrhosis, its prevalence ranging form 5%
to 20%.

Portal Hypertensive Gastropathy.

Video Endoscopic Sequence 2 of 5.

Portal Hypertensive Gastropathy.

A "snake skin" like gastric mucosal pattern consistent with
portal hypertensive gastropathy.

 

Portal Hypertensive Gastropathy.

Video Endoscopic Sequence 3 of 5.

Portal Hypertensive Gastropathy.

Portal hypertensive gastropathy is a potential cause of
bleeding in patients with liver cirrhosis.

 

Video Endoscopic Sequence 4 of 5.

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) syndrome are recently characterised entities that can be associated with gastrointestinal blood loss in patients with and without cirrhosis. Up to 65% of patients with portal hypertension from cirrhosis will develop PHG but it can also occur in the setting of non-cirrhotic portal hypertension. In patients with portal hypertension, PHG is often associated with the presence of oesophageal and/or gastric varices. The mechanisms involved in the pathogenesis of PHG have not been fully elucidated. However, regulation of gastric nitric oxide, prostaglandins, tumour necrosis factor α (TNF-α), and epidermal growth factor (EGF) production may be involved.

portal hypertensive gastropathy

Video Endoscopic Sequence 5 of 5.

Through the cardias the gastric body is observed with
portal hypertensive gastropathy, the video clip shows
esophageal varices.

 

Portal hypertensive gastropathy and gastric antral vascular ectasias (GAVE)

Video Endoscopic Sequence 1 of 6.

Portal hypertensive gastropathy and gastric antral vascular ectasias (GAVE)

This 54 year-old alcoholic male had melena and stigmata of bleeding in an previous endoscopy one week before to this one, presented with ascitis and esophageal varices that were ligated in three different sessions.

Portal hypertensive gastropathy and gastric antral vascular ectasias (GAVE) are both potential causes of upper GI bleeding. While they can be seen in patients with cirrhosis, it is quite uncommon to find them in the same patient. In portal hypertensive gastropathy, the mucosa is friable and bleeding occurs when the ectatic vessels rupture and manifest as mucosal oozing. The characteristic endoscopic appearance of fine white reticular pattern separating the areas of pinkish mucosa has been described as "snake skin" . The pathogenesis of this disorder involves congestion and hyperemia of the mucosa.

GAVE or watermelon stomach characterized by rows of flat reddish stripes radiating from the pylorus, which can sometimes be confused with portal hypertensive gastropathy. While it can be seen in patients with cirrhosis, most cases are idiopathic. Portal decompression with TIPS does not reduce bleeding caused by GAVE.
Antrectomy is reserved as a last option for patients who fail endoscopic therapies. Endoscopic coagulation with heater probe, gold probe or argon plasma coagulator (APC) obliterates the vascular ectasias and reduces the degree of blood loss . More than one session may be needed.

 

 

 

There are extensive vascular ectasia in the distal stomach

Video Endoscopic Sequence 2 of 6.

There are extensive vascular ectasia in the distal stomach.

Background: Gastric Antral Vascular Ectasia or Watermelon stomach is a rare cause of chronic gastrointestinal bleeding, often presenting as a chronic iron deficiency anemia. This condition can be associated with some other diseases such as cirrhosis, autoimmune diseases and others.

We report two patients treated with Argon Plasma Coagulation, a 68 years old male with an ethanol related cirrhosis and a 72 years old female with an idiopathic Gastric Antral Vascular Ectasia.

The characteristic endoscopic features were mistaken for many years as gastritis. Both patients presented with severe anemia requiring multiple transfusions as treatment. Due to the poor operative risk, both patients were treated with Argon Plasma Coagulation with good results.

 

 

 

There are extensive vascular ectasia in the distal stomach

Video Endoscopic Sequence 3 of 6.

There are extensive vascular ectasia in the distal stomach.

Portal hypertensive gastropathy and gastric antral vascular ectasias (GAVE) are both potential causes of upper GI bleeding.

While they can be seen in patients with cirrhosis, it is quite uncommon to find them in the same patient. In portal hypertensive gastropathy, the mucosa is friable and bleeding occurs when the ectatic vessels rupture and manifest as mucosal oozing.

The characteristic endoscopic appearance of fine white reticular pattern separating the areas of pinkish mucosa has been described as "snake skin" . The pathogenesis of this disorder involves congestion and hyperemia of the mucosa.

 

 

 

argon plasma coagulator (APC)

Video Endoscopic Sequence 4 of 6.

Endoscopic coagulation with heater probe, gold probe or argon plasma coagulator (APC) obliterates the vascular ectasias and reduces the degree of blood loss . More than one session may be needed.

GAVE or watermelon stomach characterized by rows of flat reddish stripes radiating from the pylorus, which can sometimes be confused with portal hypertensive gastropathy. While it can be seen in patients with cirrhosis, most cases are idiopathic.

Argon plasma coagulation (APC)

Video Endoscopic Sequence 5 of 6.

Argon plasma coagulation (APC) is a new noncontact electocoagulation technique which has several theoretical advantages over laser.

Argon plasma coagulation (APC)

Video Endoscopic Sequence 6 of 6.

The image as well as the video clip display the status post APC.

APC is a safe and effective short-term treatment for GAVE. The natural history of the condition is uncertain, and at medium-term follow-up GAVE is found to recur in a substantial number of patients treated with APC.
Re-treatment with APC is an option in these patients.

Portal Hypertensive Gastropathy.

Video Endoscopic Sequence 1 of 3.

Endoscopy of Portal Hypertensive Gastropathy.

Endoscopy of Portal Hypertensive Gastropathy.

Video Endoscopic Sequence 2 of 3.

Endoscopy of Portal Hypertensive Gastropathy.

Endoscopy of Portal Hypertensive Gastropathy.

Video Endoscopic Sequence 3 of 3.

Endoscopy of Portal Hypertensive Gastropathy.

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