Portal Hypertensive Enteropathy Research Articles

Predictive factors of portal hypertensive enteropathy exacerbations based on long-term outcomes

BackgroundPortal hypertensive enteropathy (PHE) is a small-bowel lesion observed in patients with portal hypertension. The clinical significance of endoscopic findings in PHE remains unclear. We aimed to clarify the clinical significance and predictive factors of capsule endoscopic findings in patients with PHE based on long-term outcomes.MethodsThis retrospective study enrolled 55 patients with PHE (33 males and 22 females; median age, 64 years; range, 23–87) followed for > 3 years using capsule endoscopy (CE) between February 2009 and May 2023. We evaluated the clinical factors affecting PHE exacerbations and the effects of PHE exacerbations on gastrointestinal bleeding by comparing exacerbated and unchanged PHE groups.ResultsOverall, 3 (5%) patients showed improvement, 33 (60%) remained unchanged, and 19 (35%) showed exacerbation on follow-up CE. In the exacerbated group, the rates of worsened fibrosis-4 index, exacerbated esophageal varices, and exacerbated portal hypertensive gastropathy were significantly higher than those in the unchanged group (21%, 32%, and 42% vs. 3%, 6%, and 12%, respectively; P < 0.05), and the rate of splenectomy was significantly lower in the exacerbated group than in the unchanged group (5% vs. 39%, respectively; P < 0.01). In multivariate analysis, exacerbation of esophageal varices and absence of splenectomy were significantly associated with PHE exacerbation. The rate of gastrointestinal bleeding after follow-up CE was significantly high in the exacerbated group (log-rank, P = 0.037).ConclusionsExacerbation of esophageal varices and splenectomy were significantly associated with exacerbation of PHE. Exacerbated PHE requires specific attention to prevent gastrointestinal bleeding.

Capsule endoscopy for small bowel bleed: Current update.

Small intestine, hitherto an obscure area for endoscopists before 2000, is now easily evaluated non-invasively using capsule endoscopy and invasively by device-assisted enteroscopies. Major advances in understanding the causes and management of small bowel diseases have been in obscure gastrointestinal (GI) bleed, currently re-named as small bowel bleed, after the discovery of capsule endoscopy. The current article is a narrative review of the technology of capsule endoscopy, its advantages and limitations, future perspective and Indian studies on its utility in patients with small bowel bleed. Till date, eight large series reporting 2319 patients with obscure GI bleed (1554 overt and 765 occult) undergoing capsule endoscopy have been reported from India. Overall yield of capsule endoscopy to detect lesions in these studies varied from 43.5% to 90%. The major causes detected in various studies for small bowel bleed include vascular malformation, portal hypertensive enteropathy, ulcer, stricture, tumor, polyps, etc. Hookworm can cause both occult as well as overt small bowel bleed as shown mainly from India. Capsule endoscopy has also been quite safe in patients with small bowel bleed as despite 0.6% to15% retention of imaging capsule in Indian studies, development of clinically evident small bowel obstruction has rarely been reported. The major limitations of capsule endoscopy include lack of maneuvrability and therapeutic capability. Research is in progress to overcome some of the limitations of the current capsule endoscopy system. It is concluded that discovery of capsule endoscopy has brought a new paradigm in GI endoscopy and explored a hitherto unexplored area of GI tract, i.e. small bowel that continued to be a black box for the endoscopists.

An image of portal hypertensive enteropathy in Roux-en-Y gastric bypass anatomy

An image of portal hypertensive enteropathy in Roux-en-Y gastric bypass anatomy

Portal hypertensive enteropathy: A disease that should not be ignored among the complications of portal hypertension

Portal hypertensive enteropathy: A disease that should not be ignored among the complications of portal hypertension

ASSESSMENT OF SIGNS OF MYOCARDIAL DYSFUNCTION IN PATIENTS WITH LIVER CYRROSIS

The article describes in detail from etiology to differential diagnosis of portal hypertensive enteropathy. Changes in the ultrastructure of the mucosal epithelium in portal hypertensive bowel disease are mainly characterized by colorectal bleeding. Bleeding is mainly caused by varicose veins of the submucosa, sudden increases in pressure in the portal vein, erosion or ulceration of the mucosal surface, obstruction of blood clotting, and a decrease in the quality or number of platelets.

GAVE bled, gave steroids, GAVE eradicated.

A 63-year-old woman presented with decompensated biopsy proven autoimmune hepatitis. This diagnosis was made several years prior at another institution, but treatment had not been initiated. She had developed ascites, hepatic encephalopathy and recurrent anaemia caused by bleeding from gastric antral vascular ectasia (GAVE) (Fig. 1). She required argon plasma coagulation to the area on a four-weekly basis. She also had evidence of portal hypertensive enteropathy at endoscopy (Fig. 1). She was started on tapering steroids for her auto-immune hepatitis and subsequently had azathioprine added.

Small-bowel mucosal changes in Egyptian cirrhotic patients with portal hypertension using capsule endoscopy versus single-balloon enteroscopy

BackgroundSmall-bowel mucosal abnormalities that may occur secondary to portal hypertension in patients with liver cirrhosis have an impact on health and quality of life. In spite of the importance of these changes, little is known about the frequency and features of small-bowel changes in cirrhotic patients with portal hypertension. Eighty cirrhotic patients with or without esophageal or gastric varices were recruited in this study as well as 60 age- and sex-matched controls. All study participants underwent capsule endoscopy. In addition, half of the patients and controls were randomized to receive single-balloon enteroscopy.ResultsThe prevalence of small-bowel mucosal changes was statistically significantly higher in cirrhotic patients than in controls; 57% versus 6.7%, respectively (p < 0.05). Cirrhotic patients with portal hypertensive gastropathy showed a significant increase in the small-bowel changes (p < 0.001). Small-bowel changes were significantly higher in patients with higher MELD and Child-Pugh scores (p < 0.001). Moreover, capsule endoscopy was more effective in the detection of small-bowel changes than single-balloon enteroscopy.ConclusionsMucosal changes associated with portal hypertensive enteropathy are more prevalent in cirrhotic patients, regardless of the presence or absence of gastric varices. Small-bowel mucosal changes in patients with portal hypertensive enteropathy were more common in patients who suffered from portal hypertensive gastropathy and were positively correlated with advanced chronic liver disease.

Lower Gastrointestinal Bleeding in Patients With Cirrhosis—Etiology and Outcomes

Lower gastrointestinal bleeding (LGIB) is a common clinical problem, and may be more prevalent among patients with cirrhosis, especially in the setting of portal hypertension and coagulopathy. However, there is extremely little data available on the subject of LGIB in patients with cirrhosis. Therefore, the primary objective of this study was to better understand the etiology and outcomes of cirrhotic patients hospitalized with LGIB. We analyzed 3,735 cirrhotic patients admitted to the Medical University of South Carolina between January 2011 and September 2018, and identified patients admitted with a primary diagnosis of hematochezia or bright red blood per rectum. Thirty patients with cirrhosis and LGIB were included in the cohort. The mean age was 56 ± 13 years, with 30% women. The mean model of end stage liver disease score was 22, and Child-Pugh (CP) scores were C: 41%, B: 33% and A: 26%. The mean Charlson Comorbidity Index was 5.6. Twenty-four (80%) patients had a clinical decompensating event (hepatic encephalopathy, ascites, esophageal varices); the mean hepatic venous pressure gradient was 14.1 mm Hg (n=8). In 33% of patients, LGIB was considered significant bleeding that necessitated blood transfusion. The most common cause of LGIB was hemorrhoids (11 patients, 37%), followed by portal hypertensive enteropathy or colopathy (7 patients, 23%). Hemoglobin levels on admission were lower in patients with CP B/C cirrhosis than in those with CP A (P < 0.001). The length of stay was 9 ± 10 days, and 5 patients died (mortality, 17%). Despite being uncommon, LGIB in cirrhotic patients is associated with a high mortality rate.

Assessment of portal hypertensive enteropathy in patients with liver cirrhosis

Background Portal hypertensive enteropathy remains difficult to diagnose in patients with cirrhosis and portal hypertension (PHT). Limited test choices exist for the inspection of the small bowel in these patients. Small-bowel endoscopy like double-balloon enteroscopy (DBE) is ideal in this situation but rarely performed. We aimed to determine the prevalence of portal hypertensive enteropathy using DBE in the patient population with PHT and correlate its presence with clinical, radiological, and histological findings. Patients and methods Thirty-two patients with PHT were included along with 10 controls without the criteria of PHT. All patients and control groups underwent blood tests, ultrasonography, gastroscopy, and enteroscopy. The small-bowel findings by DBE were categorized as inflammatory-like and vascular lesions. The small-bowel changes either endoscopically or histologically were analyzed to find out any association with various demographic, clinical, ultrasonographic, and endoscopic variables. Results The frequency of portal enteropathy in our study was 65.6% (21 patients out of 32) and it had positive correlation with the presence of esophageal varices, PHG, and Child-Pugh score. We found that there is statistically significant difference between the results of histology among patients and control groups not only in the jejunal specimen but also in the gastric and duodenal ones. The correlation with the endoscopic picture was statistically not significant. Conclusion Small-bowel mucosal and vascular changes related to PHT were seen in a significantly higher number of patients with cirrhosis and PHT.

Thrombectomy and Thrombolysis by Catheter Through Right Gastroepiploic Vein of Acute Superior Mesenteric Venous Thrombosis with Peritoneal Signs

Thrombectomy and Thrombolysis by Catheter Through Right Gastroepiploic Vein of Acute Superior Mesenteric Venous Thrombosis with Peritoneal Signs

Exacerbation of Portal Hypertensive Enteropathy after Endoscopic Injection Sclerotherapy for Esophageal Varices

Introduction: Portal hypertensive enteropathy (PHE) is a well-known small-bowel lesion that occurs with liver cirrhosis (LC) and is associated with increased hepatic venous pressure. However, it is unclear how esophageal varices (EV) treatment actually affects PHE. We aimed to analyze the effects of EV treatment on PHE. Methods: Among LC patients who underwent capsule endoscopy (CE) more than twice to confirm PHE at our hospital from February 2009 to September 2018, we targeted those with no change in the Child-Pugh classification after EV treatment for the prevention of bleeding. Patients were assigned to groups based on the EV treatment method (endoscopic injection sclerotherapy [EIS] group or endoscopic variceal ligation [EVL] group). We analyzed the PHE findings before and after treatment, and we investigated changes in the collateral vein using computed tomography imaging. Results: We analyzed 42 LC patients (27 men; mean age, 65.3 years); 20 were in the EIS group and 22 were in the EVL group. Exacerbation of PHE was significantly prevalent in the EIS group (90%) compared to that in the EVL group (50%). CE of PHE showed significantly prevalent exacerbation of villous edema in the EIS group (65%) compared to that in the EVL group (23%). Stenosis or disappearance of the feeding vessel (55%) and exacerbation of the hepatofugal collateral vein (35%) were significantly prevalent in the EIS group. Conclusions: EIS exacerbates PHE, especially villous edema, in LC patients with changes in collateral circulation.

Obscure Gastrointestinal Bleeding in Cirrhosis: Work-up and Management

Obscure gastrointestinal bleeding (OGIB) in patients with cirrhosis can be a diagnostic and therapeutic challenge. Recent advances in the approach and management of this group of patients can help to identify the source of bleeding. While the work-up of patients with cirrhosis and OGIB is the same as with patients without cirrhosis, clinicians must be aware that there are conditions exclusive for patients with portal hypertension that can potentially cause OGIB. New endoscopic and imaging techniques are capable to identify sources of OGIB. Balloon-assisted enteroscopy (BAE) allows direct examination of the small-bowel mucosa and deliver specific endoscopic therapy. Conditions such as ectopic varices and portal hypertensive enteropathy are better characterized with the improvement in visualization by these techniques. New algorithms in the approach and management of these patients have been proposed. There are new strategies for the approach and management of patients with cirrhosis and OGIB due to new developments in endoscopic techniques for direct visualization of the small bowel along with the capability of endoscopic treatment for different types of lesions. Patients with cirrhosis may present with OGIB secondary to conditions associated with portal hypertension.

The Usefulness of New-Generation Capsule Endoscopy in Patients with Portal Hypertensive Enteropathy.

The Usefulness of New-Generation Capsule Endoscopy in Patients with Portal Hypertensive Enteropathy.

Video Capsule Endoscopy in the Assessment of Portal Hypertensive Enteropathy.

Background The features of the portal hypertension enteropathy (PHE) vary from mild mucosal changes to varices with or without bleeding. The prevalence and the development are not fully understood. Aim Our aim is to examine the prevalence and the different manifestations of PHE using video capsule endoscopy (VCE). Methods It is a single center retrospective study of patients with cirrhosis, who had VCE. Based on the published literature, we divided the PHE lesions into vascular lesions and mucosal lesions. Results Of the 100 patients with cirrhosis that had a VCE study, the mean age was 62.82 years. Male gender was predominant (64%), while Caucasians represented 82% of the cohort. The most common etiology of cirrhosis was chronic alcohol abuse followed by chronic hepatitis C virus and nonalcoholic steatohepatitis. VCE detected small bowel lesions in 71% of the patients while the features of PHE were found in 65% from the total cohort. AVMs and inflammatory changes were the most common findings, followed by bleeding. More than 50% of the lesions were vascular in nature. The risk of finding PHE in decompensated cirrhosis is twice that in compensated cirrhosis. Forty-five patients had negative EGD exam for any active bleeding, esophageal varices, portal hypertensive gastropathy, or gastric varices. Of these, 69% had features of PHE in their VCE. Conclusions VCE detected small bowel lesions in 71% of our cohort. There is a high prevalence of PHE in decompensated cirrhosis. Vascular lesions are the most common finding in the small bowel of this population.

Mucosal Changes in the Small Intestines in Portal Hypertension: First Study Using the Pillcam SB3 Capsule Endoscopy System

Background/AimsTo evaluate patients with portal hypertension (PH) of varied etiologies for portal hypertensive enteropathy (PHE) using the PillCam SB3 capsule endoscopy (CE) system. MethodsConsecutive patients with PH presenting with unexplained anemia and/or occult gastrointestinal bleeding were evaluated using the PillCam SB3 CE system. Abnormal findings were categorized as vascular or non-vascular. The patients with ongoing bleeding caused by PHE were treated. The correlation of the CE scores of PHE with the clinical, laboratory, and endoscopic features was determined. ResultsOf the 43 patients included in the study, 41 (95.3%) showed PHE findings. These included varices (67.4%), red spots (60.5%), erythema (44.2%), villous edema (46.5%), telangiectasia (16.3%), and polyps (16.3%). The CE scores varied from 0 to 8 (mean±standard deviation, 4.09±1.8). Five patients (11.6%) showed evidence of ongoing or recent bleeding due to PHE. Three of these five patients underwent endotherapy, and one patient underwent radiological coil placement. ConclusionsThe PillCam SB3 CE system revealed a high prevalence of PHE in the patients with PH. Using this system, evidence of bleeding due to PHE was found in a small but definite proportion of the patients.

Capsule Endoscopy for Obscure Gastrointestinal Bleeding: A Single‑Center Experience

ABSTRACT Background: Capsule endoscopy (CE) has an established role in evaluating obscure gastrointestinal bleeding (OGIB). The aim was to know the diagnostic yield of CE and spectrum of OGIB. Materials and Methods: In this retrospective study, we evaluated all the patients with obscure gastrointestinal bleed using MiroCam capsule endoscope (IntroMedic, Seoul, Korea) between February 2014 and March 2018. Clinical data, ancillary investigations, and response to specific treatment were considered to confirm CE findings. Results: Out of 102 patients included in the study (mean age 54.5 ± 16.1 years, male: female ratio = 1.83:1) OGIB‑overt and OGIB‑occult was present in 46 and 56 patients, respectively. Diagnostic yield of CE was similar in both the groups (overt‑37/46, 80.4% versus occult‑37/56, 66.5%) (P ≥ 0.05), although there was trend to find more lesions in overt group. Overall positive diagnostic yield was 72.5%. Lesions detected were vascular malformations in 21 (20.5%), nonsteroidal anti‑inflammatory drug enteropathy in 13 (12.7%), small bowel ulcerations in 27 (26.4%), which were further divided into three subgroups (a) nonspecific ulcerations 11 (10.7%), (b) tubercular ulcer with/without stricture in 7 (6.8%) and (c) serpiginous ulcers and fissuring with cobble‑stone appearance suggestive of Crohn’s disease in 9 (8.8%), portal hypertensive enteropathy in 5 (4.9%), worm infestation (hookworms in 3, roundworms 1) in 4 (3.9%), and small bowel tumour in 1 (0.98%) patient. Overall, 56.7% patients were having definitive (P2) lesions (Saurin classification). Two patients had retention of capsule, but none developed intestinal obstruction. Capsule was removed with surgical intervention. Conclusion: CE has high diagnostic yield, relative safety and tolerability, and it is an important diagnostic tool for OGIB. Small bowel tuberculosis, Crohn’s disease and Worm infestation continue to be commonly recognized causes of OGIB in developing countries like India.

Predictive Factors of Portal Hypertensive Enteropathy Exacerbation in Patients with Liver Cirrhosis: A Capsule Endoscopy Study

Background/Aims: The clinical course and exacerbation of portal hypertensive enteropathy (PHE) are yet to be fully clarified. This study aimed to identify factors related to PHE exacerbation in patients with liver cirrhosis (LC). Methods: Fifty patients with LC (33 male; mean age, 67 years), who underwent capsule endoscopy (CE) at the Hiroshima University Hospital between February 2009 and September 2015, were followed up for >6 months. Exacerbation is defined as the appearance of new lesions or worsening of existing lesions. The association between PHE exacerbation and the clinical factors was evaluated. Results: PHE exacerbation was identified in 24 out of 50 (48%) of cases: erythema (14 cases); angioectasia (11 cases); erosions (9 cases); villous edema (8 cases); and esophageal varices (EVs; 6 cases). The following factors were significantly associated with PHE exacerbation: portosystemic shunts, EVs and portal hypertensive gastropathy (PHG) exacerbation. After therapy, CE findings among the 24 cases were as follows: villous edema (19 cases); erythema (17 cases); angioectasia (16 cases); erosions (12 cases); and EVs (9 cases), and no observable abnormalities in 2 cases. On multivariate analysis, exacerbation of EVs and PHG were independent predictors of PHE exacerbation. Conclusion: EVs and PHG exacerbation may predict PHE exacerbation in patients with LC.

Clinical significance of small‐bowel villous edema in patients with liver cirrhosis: A capsule endoscopy study

The relationship between the presence of villous edema (VE) in portal hypertensive enteropathy and clinical factors remains unclear. The aim of this study was to reveal the clinical factors related to VE in patients with liver cirrhosis (LC), and investigate the clinical significance of VE. Between February 2009 and September 2016, 363 consecutive patients with LC underwent capsule endoscopy for diagnosing portal hypertensive enteropathy at Hiroshima University Hospital. We evaluated the relationship between the presence of VE and patients' clinical characteristics, findings of esophagogastroduodenoscopy and computed tomography, and survival time. Villous edema was observed in 131 patients (36%), and severe lesions were found in 71 (20%). The presence of VE was significantly greater in patients with Child-Pugh classification B or C, esophageal varices, portal hypertensive gastropathy (PHG), ascites, portal vein thrombosis (PVT), and splenomegaly. In multivariate analysis, Child-Pugh class B or C, esophageal varices, PVT, and splenomegaly were significant predictive factors for the presence of VE. Severe VE was significantly greater in patients with Child-Pugh class B or C, serum albumin level≤3.2mg/dL, PHG, and PVT. In multivariate analysis, PHG, Child-Pugh class B or C, PVT, were significant predictive factors for severe VE. Clinical factors related to portal hypertension were significantly correlated with VE. In particular PVT was correlated with the appearance and exacerbation of VE. Periodic capsule endoscopy in LC patients may lead to early detection of portal hypertension and PVT.

Inter and intra-observer concordance for the diagnosis of portal hypertension gastropathy.

At present there is no fully accepted endoscopic classification for the assessment of the severity of portal hypertensive gastropathy (PHG). Few studies have evaluated inter and intra-observer concordance or the degree of concordance between different endoscopic classifications. To evaluate inter and intra-observer agreement for the presence of portal hypertensive gastropathy and enteropathy using different endoscopic classifications. Patients with liver cirrhosis were included into the study. Enteroscopy was performed under sedation. The location of lesions and their severity was recorded. Images were videotaped and subsequently evaluated independently by three different endoscopists, one of whom was the initial endoscopist. The agreement between observations was assessed using the kappa index. Seventy-four patients (mean age 63.2 years, 53 males and 21 females) were included. The agreement between the three endoscopists regarding the presence or absence of PHG using the Tanoue and McCormack classifications was very low (kappa scores = 0.16 and 0.27, respectively). The current classifications of portal hypertensive gastropathy have a very low degree of intra and inter-observer agreement for the diagnosis and assessment of gastropathy severity.

Portal Hypertensive Polypoid Enteropathy Without Overt Endoscopic Features of Portal Hypertension: A Case Report

Introduction: Portal hypertensive polypoid enteropathy is an under recognized complication of portal hypertension. It is a rare manifestation of portal hypertensive enteropathy (PHE), polypoid lesions are seen in about 0.3% cases in the small intestine. Endoscopic findings of portal hypertension may or may not be present. Case description: A 60 year-old female with a history of liver cirrhosis from NAFLD and chronic GI bleeding was referred for evaluation of transfusion-dependent anemia requiring IV iron and packed red blood cells. Encephalopathy was her only known complication from cirrhosis. Previous work-up revealed a polypoid lesion in the duodenum which was removed (histology: chronic active duodenitis with ulceration, polypoid inflamed granulation tissue). EGD did not show varices, GAVE, or portal hypertensive gastropathy. She also had a history of large internal hemorrhoids and diverticulosis which were previously treated. Despite management of suspected lesions, anemia persisted with hem occult positive stools. VCE was performed using PillCam system which showed a 6-8mm villous polyp with surface erosion without bleeding in the proximal duodenum. Clusters of erythema and red villi were noted in small intestine which did not appear to be discrete angiodysplasias. At mid-small intestine (57% transit) 1cm sessile polypoid lesion with active bleeding was noted that appeared to be an inflammatory polyp or granulation tissue. Upper DBE showed small bowel findings consistent with portal enteropathy without discrete AVM (Figure 1). Small inflammatory polyps were removed from duodenum. Histopathology showed benign inflammatory polyp c/w portal enteropathy. Lower DBE revealed a 1 cm sessile polyp in mid- ileum (40 cm upstream of colon) which matched the lesion seen on VCE. Polyp was removed with hot snare. Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations (Figure 2, 3). The findings were suggestive of polypoid portal hypertensive enteropathy.Figure: Upper DBE showed small bowel findings consistent with portal enteropathy without discrete AVM.Figure: Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations.Figure: Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations.Discussion: Introduction of VCE and deep enteroscopy has enabled us to perform diagnostic and therapeutic evaluation of small bowel in PHE. Portal hypertensive polypoid enteropathy should be kept high in the differential in patient s with liver cirrhosis presenting with occult GI blood loss. Management of PHE is yet to be standardized, individualized approach should be sought.