S2807 Portal Hypertensive Polyps as a Unique Cause of Bleeding in Cirrhosis

Abstract

Introduction: Portal hypertension is due to resistance to portal blood flow commonly due to a fibrotic, cirrhotic liver. This leads to a multitude of complications including esophageal varices, portal hypertensive gastropathy, and ascites. Portal hypertensive polyps (PHP) is a recently described entity with prevalence estimated to be 1-3% of all gastric polyps found in cirrhotics especially since gastric polyps in the general population is already a relatively uncommon finding. We present a patient with complications due to PHP. Case Description/Methods: A 60-year-old male with a history of alcoholic liver cirrhosis (MELD 8) and esophageal varices that were previously banded, presented to the ED with melena and a hemoglobin of 5.9 gm/dl. The first EGD showed gastric antral-pyloric polyps, likely thought to be portal hypertensive polyps, with active minor oozing. There was one large polyp 2.5 cm in size and multiple smaller polyps in the surrounding area. The decision was made to intervene on these polyps during a repeat EGD. Argon plasma coagulation (APC) was used to coat the polyps with successful hemostasis. A subsequent outpatient EGD showed stable polyps without bleeding. The patient was referred for transjugular intrahepatic portosystemic shunt (TIPS) placement in hopes to reduce portal hypertension to limit future episodes of GI bleeding. Discussion: Being a relatively new phenomenon, the diagnostic criteria/clinical relevance for PHP is not yet clear. The histological characteristics of PHP are similar to hyperplastic polyps with foveolar hyperplasia and proliferating ectatic capillaries in the lamina propria. Furthermore, most cases of PHP involve multiple lesions. However, studies have shown that they do not degenerate to malignancy. Independent predictors of PHP include Child-Pugh > 6, MELD > 16, and rubber band ligation of varices. Variceal ligation is thought to be due to increased formation of portosystemic shunts leading to increase portal pressure in the gastric wall inducing proliferation/angiogenesis; our patient did have a history of banded varices. Studies have also shown no active bleeding from the PHP in any of the endoscopies, but our instance of PHP did have active bleeding. Recurrence after polypectomy is common and it is not recommended to routinely remove the polyps, but APC can be used for bleeding polyps. Ultimately TIPS has shown to reverse portal hypertensive gastropathy but there is no studies on its utility in treating PHP; as this area of focus demands further study.Figure 1.: Portal Hypertensive Polyp in Gastric Antrum.