Effect of Endoscopic Argon Plasma Coagulation on Gastrointestinal Blood Loss Due to Portal Hypertensive Gastropathy

Abstract

Background: Portal hypertensive gastropathy (PHG) is one of the clinical conditions that can cause chronic gastrointestinal hemorrhage in patients with cirrhosis, manifested by chronic anemia. It is generally diagnosed on the basis of endoscopic features. A new thermal modality has recently been introduced to endoscopy: the argon plasma coagulator (APC). Hemostasis is a main target for the use of APC and its role in ceasing PHG related acute and chronic bleeding is being efficient and safe when studied in the past few years. Aim of the study: To evaluate the role of argon plasma coagulation in comparison with non-selective beta blockers for the treatment of chronic blood loss and iron deficiency anemia in cirrhotic patients with severe portal hypertensive gastropathy. Patients and methods: This study included 112 cirrhotic anemic patients who had severe PHG. The patients were divided into two groups, group (A) included 56 patients who had argon plasma coagulation (APC) sessions and group (B) included 56 patients who received propranolol as oral therapy. Response to the treatment was assessed by the change in hemoglobin and iron parameters over the following three months after the start of therapy. Results: On comparing laboratory investigations between 1st visit and one, two and three months after the 1st visit in group (A) patients, there was a highly significant increase in hemoglobin level, serum iron and serum ferritin with a significant decrease in TIBC. This means that there was an overall improvement of anemia and iron deficiency. On comparing laboratory investigations between 1st visit and one, two and three months after the 1st visit in the use of beta-blockers (group B) is associated with the gradual increase in the mean of hemoglobin, serum iron, and serum ferritin and gradual decrease of TIBC. There was statistically significant difference between the two groups as regards the changes in hemoglobin and iron study after one, two and three months respectively when compared with the first visit that means that the increase in hemoglobin, serum ferritin, serum iron is more in APC group patients than beta-blockers group patients and the decrease in TIBC is more in APC group patients than beta-blockers group patients, so the improvement in hemoglobin and iron study variables is better in APC group patients than detected in beta-blockers group patients. Taking into account portal vein dilatation and decreased flow velocity, two physiological changes associated with portal hypertension, the “congestion index” was used to assess portal hypertension which is the ratio of portal vein crosssectional area (cm2) to mean portal vein flow velocity (cm/sec). In our study the mean congestion index of the main portal vein was 0.18 (cm × sec) and it is significantly higher in bleeder than in non-bleeder group and at a cutoff limit of congestion index of portal vein 0.24 (cm × sec) the sensitivity is 83% and specificity is 96% in discriminating bleeder from non-bleeder group. Conclusion: The use of either argon plasma coagulation (APC) or beta-blockers in controlling the chronic blood loss from congestive gastropathy shows significant improvement in hemoglobin and iron study variables with both but the significant improvement in APC group patients than in beta-blockers group patients recommended the use of APC to control the chronic blood loss from congestive gastropathy.