Abstract
Portal hypertensive gastropathy is a vascular disorder of the gastric mucosa distinguished by ectasia of the mucosal capillaries and submucosal veins without inflammation. During 1988 to 1993, 12 patients with biopsyproven cirrhosis (10 alcoholic, 2 posthepatitic) were evaluated and treated prospectively by portacaval shunt for active bleeding from severe portal hypertensive gastropathy. Eleven patients had been hospitalized for bleeding three to nine times previously, and one was bleeding uncontrollably for the first time. Requirement for blood transfusions ranged from 11 to 39 units cumulatively, of which 8 to 30 units were required specifically to replace blood lost from portal hypertensive gastropathy. Admission findings were ascites in 9 patients, jaundice in 8, severe muscle wasting in 10, hyperdynamic state in 9. Child's risk class was C in 7, B in 4, A in 1. Ten of the 12 patients had previously received repetitive endoscopic sclerotherapy for esophageal varices, which has been reported to precipitate portal hypertensive gastropathy. Eight patients had failed propranolol therapy for bleeding. Portacaval shunt was performed emergently in 11 patients and electively in 1, and permanently stopped bleeding in all by reducing the mean portal vein-inferior vena cava pressure gradient from 251 to 16 mm saline. There were no operative deaths, and two unrelated late deaths after 13 and 24 months. During 1 to 6.75 years of followup, all shunts remained patent by ultrasonography, the gastric mucosa reverted to normal On serial endoscopy, and there was no gastrointestinal bleeding. Recurrent portal-systemic encephalopathy developed in only 8% of patients. Quality of life was generally good. It is concluded that portacaval shunt provides definitive treatment of bleeding portal hypertensive gastropathy by eliminating the underlying cause, and makes possible prolonged survival with an acceptable quality of life.
Highlights
The senior Orloff and colleagues propose an additional indication for their preferred surgical operation, the total portacaval shunt [1]
Subsequent investigations have shown that the pathogenesis of Portal hypertensive gastropathy (PHG) is a consequence of adverse events in the gastric mucosal microvasculature [8-10]
Ongoing work at the basic science level continues to elucidate the functional and structural features of the portal hypertensive gastric mucosa that result in PHG [8-12]
Summary
The senior Orloff and colleagues propose an additional indication for their preferred surgical operation, the total portacaval shunt [1]. Portal hypertensive gastropathy (PHG), as Orloff points out, is a recently-characterized lesion that may result in significant (albeit usually not massive) upper gastrointestinal hemorrhage Orloff et al accrued 12 patients over a 5 year period with PHG associated with bleeding that was deemed severe enough to warrant operative intervention [1]. Ongoing work at the basic science level continues to elucidate the functional and structural features of the portal hypertensive gastric mucosa that result in PHG [8-12].
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