Hypertensive Gastropathy Research Articles

Frequency of Portal Gastropathy in Child Pugh Class A, B, C in Chronic Liver Disease

Liver disease progresses through four stages of inflammation, fibrosis, cirrhosis leading to hepatocellular carcinoma and liver failure. Aims: To check the frequency of portal gastro-pathy in child Pugh class A, B, C in chronic liver disease. Study Design: Cross sectional study. Methodology: Patients (n=246) with chronic liver disease were included and classified based on the Child-Pugh classification and grouped into category A (good hepatic function), category B (moderately impaired hepatic function and category C (advanced hepatic dysfunction). Findings suggestive of portal gastropathy were noted in the endoscopy reports and were classified as mild or severe according to McCormack criteria. ALT, platelets, Haemoglobin and INR levels were also recorded. Statistical analysis: Data was analyzed using SPSS version 26. Results were presented as frequency and percentage. Age was presented as mean± SD. Results: Out of total 246 patients 155 (63%) were males and 91 (37%) were females. Mean age of the patients was 45.1 ± 10.1 years. 142 (57.7%) patients were of child PUGH class A, 66 (26.8%) were of class B and 38 (15.4%) were of class C. Frequency of portal gastropathy was 62.2% (n=153). In our study 57.7% patients in child PUGH class A, 69.6% of Child PUGH class B and 65.7% in PUGH class C were positive with PHG findings. Conclusion: It was concluded that Portal hypertensive gastropathy was not significantly related to the Child Pugh classification of liver disease. However, an increase in ALT levels depicted the severity of liver damage. Keywords: Child PUGH Classification, Chronic Liver Disease, Portal Hypertension and Portal Hypertensive Gastro-pathy.

Portal Hypertension and Current Endoscopic Management

AbstractPortal hypertension is a difficult to treat sequelae of end stage of liver disease, and is associated with a variety of complications. Notably, it can lead to significant gastrointestinal bleeding, which carries a high risk of mortality. Sources of portal hypertensive bleeding include esophageal and gastric varices, portal hypertensive gastropathy and ectopic varices. Fortunately, endoscopic techniques are effective in both prevention and management of acute bleeding, and their application and expansion has led to improved outcomes. Endoscopy plays a pivotal role as it allows for direct visualization and diagnosis as well as immediate intervention. There are several endoscopic techniques available for the treatment of esophageal varices including band ligation, glue therapy and sclerotherapy. There are, however, gray areas within the management of portal hypertensive bleeding such as the management of portal hypertensive gastropathy and gastric variceal bleeding, both of which can be more challenging to treat endoscopically. Thus, there is growing interest regarding how novel advanced therapeutic techniques can address these areas with a focus on endoscopic ultrasound guided therapies. This article will review both traditional and novel endoscopic techniques used in the management and prevention of portal hypertensive associated bleeding.

Upper Gastrointestinal Cancer and Liver Cirrhosis.

Simple SummaryThere is a higher incidence rate of upper gastrointestinal cancer in those with liver cirrhosis. The contributing factors include gastric ulcers, congestive gastropathy, zinc deficiency, alcohol drinking, tobacco use and gut microbiota. Most of the de novo malignancies that develop after liver transplantation for cirrhotic patients are upper gastrointestinal cancers. The surgical risk of upper gastrointestinal cancers in cirrhotic patients with advanced liver cirrhosis is higher.The extended scope of upper gastrointestinal cancer can include esophageal cancer, gastric cancer and pancreatic cancer. A higher incidence rate of gastric cancer and esophageal cancer in patients with liver cirrhosis has been reported. It is attributable to four possible causes which exist in cirrhotic patients, including a higher prevalence of gastric ulcers and congestive gastropathy, zinc deficiency, alcohol drinking and tobacco use and coexisting gut microbiota. Helicobacter pylori infection enhances the development of gastric cancer. In addition, Helicobacter pylori, Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans also contribute to the development of pancreatic cancer in cirrhotic patients. Cirrhotic patients (especially those with alcoholic liver cirrhosis) who undergo liver transplantation have a higher overall risk of developing de novo malignancies. Most de novo malignancies are upper gastrointestinal malignancies. The prognosis is usually poor. Considering the surgical risk of upper gastrointestinal cancer among those with liver cirrhosis, a radical gastrectomy with D1 or D2 lymph node dissection can be undertaken in Child class A patients. D1 lymph node dissection can be performed in Child class B patients. Endoscopic submucosal dissection for gastric cancer or esophageal cancer can be undertaken safely in selected cirrhotic patients. In Child class C patients, a radical gastrectomy is potentially fatal. Pancreatic radical surgery should be avoided in those with liver cirrhosis with Child class B or a MELD score over 15. The current review focuses on the recent reports on some factors in liver cirrhosis that contribute to the development of upper gastrointestinal cancer. Quitting alcohol drinking and tobacco use is important. How to decrease the risk of the development of gastrointestinal cancer in those with liver cirrhosis remains a challenging problem.

Effect of olive oil on the stomach of adult male albino rats with induced liver fibrosis

Background Liver fibrosis proceeds to portal hypertension, and portal hypertensive gastropathy is considered its main complication. Olive oil is associated with human health benefits. Aim To study the effect of olive oil on the stomach after induction of liver fibrosis. Materials and methods A total of 50 healthy adult male albino rats were randomly divided into two groups, including group I (control group) and group II (experimental group), which were subdivided into four subgroups: olive oil-treated subgroup IIa received 5 ml/kg body weight olive oil daily by an orogastric tube for 4 weeks, subgroup IIb received 0.1 ml/100 g body weight carbon tetrachloride (CCL4) by intraperitoneal injection twice per week for 4 weeks, subgroup IIc received both olive oil and CCL4 at the same dose of subgroups IIa and IIb for the same period, and subgroup IId received CCL4 for 4 weeks and then olive oil was given alone for another 4 weeks as the same dose in subgroups IIa and IIb. Stomach specimens were processed for histological and immunohistochemical study. Results Subgroup IIb showed disorganized and atrophic gastric glands with severe interstitial hemorrhage and diffuse inflammatory infiltrates. The parietal cells had vacuolated cytoplasm with irregular nuclei, and others had karyolitic nuclei with vacuolization of the cytoplasm of some chief cells. Subgroup IIc showed significant improvement, and subgroup IId showed nonsignificant improvement. Conclusion The use of olive oil partially improved the histological changes in the stomach as a result of liver fibrosis.

Endoscopic Findings in Patients With Upper Gastrointestinal Bleeding in Ogun State, Nigeria.

IntroductionAlthough the global incidence of upper gastrointestinal bleeding (UGIB) appears to have reduced substantially in the past few decades, acute UGIB still carries significant morbidity and mortality worldwide. There are currently no published data on UGIB in Ogun State, Nigeria. This study examined the endoscopic findings in patients with UGIB in Ogun State. MethodologyThe study was a retrospective cross-sectional survey of patients with UGIB who had upper gastrointestinal endoscopy at three endoscopy centers in Ogun State, Southwest Nigeria, from January 2015 to December 2021. Patients’ data, which included age, gender, and endoscopic findings, were extracted from the endoscopy registers into a spreadsheet and analyzed statistically. Summary statistics included means ± standard deviation for continuous variables and frequencies and percentages for categorical variables. Categorical variables were compared for differences by chi-square test or Fisher’s exact test as appropriate. The statistical significance cutoff was p-value <0.05.ResultsA total of 171 had endoscopy for UGIB during the period under review but 168 had complete data. Out of the 168, 113 (67.3%) were males, giving a male-to-female ratio of 2:1. The mean age of the patients was 52.4 ± 18.1 years, with an age range of 7-85 years. The modal age group was ≥60 years (75; 39.9%). The most common endoscopic finding was peptic ulcer disease (77; 45.8%), followed by esophagogastric varices (27; 16.1%), erosive mucosal disease (25; 14.9 %), portal hypertensive gastropathy (15; 8.9%), suspected malignancies (11; 6.6%), hemorrhagic gastritis (7; 4.2%), gastric antral vascular ectasia (2; 1.2%), and Mallory-Weiss tear (1; 0.6%), respectively. Forty-four patients (26.2%) had no lesion that could explain UGIB. ConclusionPeptic ulcer disease was the most common cause of UGIB among our patient population, and the elderly male patients were the most affected.

The clinical applicability of percutaneous splenic vein stent implantation for pancreatic portal hypertension

BackgroundPancreatic portal hypertension (PPH) is a type of extrahepatic portal hypertension. We compared the clinical efficacy of different treatment methods for PPH caused by splenic vein stenosis in chronic pancreatitis.MethodsThis article retrospectively analyzed the PPH cases that were caused by splenic vein stenosis after chronic pancreatitis. Patients were divided into three groups according to the different treatments: splenic vein stent implantation (stent group), splenectomy, and only medications (conservative group). The treatment effects from each group were compared.ResultsA total of 33 patients were retrospectively analyzed in this study (9, 12, and 12 patients in each group respectively). All the procedures were successful in the stent and splenectomy groups. During the follow-up, no patient had gastrointestinal bleeding recurrence in the stent and splenectomy groups. However, in the conservative group, the incidence of portal hypertensive gastropathy and upper gastrointestinal bleeding were 50% and 25%. In the stent group, all the varicose veins at the base of the stomach had shrunk by varying degrees, and the red color signs regressed. The stent patency rate was 100%. No major complication occurred. The average platelet count at 1, 3, 6-months postoperatively were all significantly higher than the preoperative value (P < 0.05). The average postoperative hospital stay duration was significantly shorter than that of the splenectomy group (3.1 ± 1.4 days vs. 16.1 ± 8.1 days; P < 0.05). In the splenectomy group, postoperative fever occurred in 4 patients. Postoperative infection occurred in 2 patients (one with abdominal cavity infection and the other with incision infection). Delayed abdominal bleeding occurred in one patient. Portal vein thrombosis occurred in 2 patients during follow up.ConclusionPercutaneous splenic vein stent implantation for PPH treatment reduces the risk of gastrointestinal bleeding with minimal invasive. It has a high safety and reliable efficacy and is worthy of further clinical promotion.

Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review.

BACKGROUNDAcute non-variceal bleeding accounts for approximately 20% of all-cause bleeding episodes in patients with liver cirrhosis. It is associated with high morbidity and mortality therefore prompt diagnosis and endoscopic management are crucial.AIMTo evaluate available data on the efficacy of endoscopic treatment modalities used to control acute non-variceal gastrointestinal bleeding (GIB) in cirrhotic patients as well as to assess treatment outcomes.METHODSEmploying PRISMA methodology, the MEDLINE was searched through PubMed using appropriate MeSH terms. Data are reported in a summative manner and separately for each major non-variceal cause of bleeding. RESULTSOverall, 23 studies were identified with a total of 1288 cirrhotic patients of whom 958/1288 underwent endoscopic therapy for acute non-variceal GIB. Peptic ulcer bleeding was the most common cause of acute non-variceal bleeding, followed by portal hypertensive gastropathy, gastric antral vascular ectasia, Mallory-Weiss syndrome, Dieaulafoy lesions, portal hypertensive colopathy, and hemorrhoids. Failure to control bleeding from all-causes of non-variceal GIB accounted for less than 3.5% of cirrhotic patients. Rebleeding (range 2%-25%) and mortality (range 3%-40%) rates varied, presumably due to study heterogeneity. Rebleeding was usually managed endoscopically and salvage therapy using arterial embolisation or surgery was undertaken in very few cases. Mortality was usually associated with liver function deterioration and other organ failure or infections rather than uncontrolled bleeding. Endoscopic treatment-related complications were extremely rare. Lower acute non-variceal bleeding was examined in two studies (197/1288 patients) achieving initial hemostasis in all patients using argon plasma coagulation for portal hypertensive colopathy and endoscopic band ligation or sclerotherapy for bleeding hemorrhoids (rebleeding range 10%-13%). Data on the efficacy of endoscopic therapy of cirrhotic patients vs non-cirrhotic controls with acute GIB are very scarce.CONCLUSIONEndotherapy seems to be efficient as a means to control non-variceal hemorrhage in cirrhosis, although published data are very limited, particularly those comparing cirrhotics with non-cirrhotics and those regarding acute bleeding from the lower gastrointestinal tract. Rebleeding and mortality rates appear to be relatively high, although firm conclusions may not be drawn due to study heterogeneity. Hopefully this review may stimulate further research on this subject and help clinicians administer optimal endoscopic therapy for cirrhotic patients.

EVALUATION OF HELICOBACTER PYLORI FREQUENCY AND GASTRIC ANTRUM PATHOLOGY FINDINGS IN PATIENTS WITH PORTAL HYPERTENSION

Objective: In our study, we aimed to evaluate the prevalence of Helicobacter pylori (H. Pylori) and the characteristics of antrum pathologies in patients with portal hypertensive gastropathy. Materials and Methods: Antrum pathologies and the presence of H. Pylori evaluated with Giemsa stain in gastroscopies of 203 patients with portal hypertensive gastropathy. Results: A total of 203 patients, 119 male, 84 female, with portal hypertensive gastropathy was included in our study. In patients with portal hypertension, the rate of H. Pylori positivity was 15.3%. This rate was determined as 18.5% under 65 years old and 8.8% over 65 years old. On the basis of gender, H. Pylori positivity rates were 21.8% in male patients and 6% in female patients. The most common antrum pathologies in the patients, in order of frequency, were reactive gastropathy with a rate of 41.4%, active gastritis with a rate of 23.6%, and edema with a rate of 22.2%. The rate of intestinal metaplasia was found to be 9.9%. Conclusion: In the patients with portal hypertension included in our study, the H. Pylori positivity rate was found to be 15.3%. This rate was found to be below the H. Pylori positivity rate in our country. The most common antrum pathology in the patients was reactive gastropathy with a rate of 41.4%, while the rate of intestinal metaplasia was found to be 9.9%.

Portal Hypertensive Gastropathy in Liver Cirrhosis: Prevalence, Natural History, and Risk Factors.

Objective Portal hypertensive gastropathy (PHG) is a common finding in patients with liver cirrhosis (LC) and may cause both acute and chronic bleeding. A number of risk factors for PHG have been identified. The present study explored the characteristics of Japanese patients with LC who develop PHG.MethodsClinical findings (age, sex, etiology, the presence of esophageal varices, splenomegaly and severity of LC), laboratory data, and whether or not atrophic gastritis was found on endoscopy were retrospectively reviewed in patients with LC who had undergone esophagogastroduodenoscopy. PHG was endoscopically graded as absent, mild, or severe.ResultsOf 262 patients with LC (mean age, 69 years old; 145 men), 158 had no PHG, 41 had mild PHG, and 63 had severe PHG. In a univariate analysis, a younger age, male sex, non-viral etiology, absence of atrophic gastritis, presence of esophageal varices, splenomegaly, severe LC, low platelet count, and low hemoglobin concentration were associated with PHG. A multivariate analysis showed a significant association of PHG with the absence of atrophic gastritis (p<0.048), presence of esophageal varices (p<0.001), non-viral etiology (p<0.033), splenomegaly (p<0.048), and severe LC (p<0.005). There were no cases of massive bleeding from PHG during follow-up.ConclusionEsophageal varices, splenomegaly, severe liver cirrhosis, the absence of atrophic gastritis, and etiology were found to be risk factors for PHG in Japanese patients.

Serum serotonin as a non-invasive marker of portal hypertensive gastropathy in Egyptian patients with HCV-related liver cirrhosis.

Portal hypertensive gastropathy (PHG) is an important complication of portal hypertension (PHT) in cirrhotic patients. We aimed in the current study to investigate the validity of serum serotonin as a probable non-invasive marker for PHG in cirrhotic patients with PHT. We conducted this study on 100 HCV-related cirrhotic patients divided into three groups according to their endoscopic findings; group I: patients with no endoscopic signs of PHG; group II: patients with mild PHG; and group III: patients with severe PHG. All subjects had routine laboratory investigations, serum serotonin level using ELISA kits, calculation of Child's score, abdominal ultrasound, and upper GIT endoscopy. Serum serotonin was significantly higher in those with PHG than those without (t= 5.128, p <0.001). Moreover, it was significantly higher in patients with severe degree of PHG than those with mild PHG (t=7.357, p<0.001). Furthermore, a significant positive correlation was observed between serum serotonin and Child Pugh score (t=7.357, p<0.001). Roc curve analysis revealed that serum serotonin at a level ? 26.5 ng/ml had a 78.82% sensitivity, 73.33% specificity, and accuracy of 78% to discriminate between those with signs of PHG and those without. Serum serotonin is a valuable non-invasive marker of PHG in HCV-cirrhotic patients. Furthermore, its serial measurements could be used to monitor disease progression.

Discrimination between Portal Hypertensive Gastropathy and Helicobacter pylori-related Gastritis.

Discrimination between Portal Hypertensive Gastropathy and Helicobacter pylori-related Gastritis.

Pseudoaneurysm bleed in chronic pancreatitis: beware of multiple feeding vessels-a case report

Gastroduodenal artery (GDA) pseudoaneurysm is a rare but potentially fatal complication in chronic pancreatitis. Managing GI bleed in chronic pseudocyst due to ruptured pseudoaneurysm having multiple feeding vessels and that too in a background of portal hypertension is a challenging task. A 43 year old male patient with chronic calcific pancreatitis presented to our department with 10 days history of malena and drop in hemoglobin. He under micro coil embolization of GDA 12 days before in another hospital for ruptured GDA pseudoaneurysm with upper GI bleed. Upper GI endoscopy revealed grade II-III esophageal varices with portal hypertensive gastropathy with blood in 2nd part of duodenum. CECT scan revealed features of chronic calcific pancreatitis with pseudocyst and GDA pseudoaneurysm with intracystic bleed. Patient again underwent coil embolization in our hospital. However, the patient again developed GI bleed. Patient was taken for emergency laparotomy and found to have bleed from splenic artery as well as GDA pseudoaneurysm into the pseudocyst. Transcystic pseudoaneurysm ligation with ligation of intracystic bleeding vessels and lateral pancreaticojejunostomy was done. Postoperatively patient recovered well. Rupture of pseudoaneurysm in chronic pancreatitis is associated with almost 100% mortality if untreated. Though radiological intervention should be the primary modality of treatment, low threshold for surgery should be kept, considering multiple feeding vessels to the pseudocyst pseudoaneurysm, which may be missed in angiography

A117 MANAGEMENT OF VARICEAL BLEEDING WITH ENDOSCOPIC INJECTION OF N-BUTYL-2-CYANOACRYLATE IN PREGNANCY

BackgroundAlthough variceal bleeding is rare in pregnancy, pregnant woman with non-cirrhotic portal hypertension are at greater risk of variceal hemorrhage due to increased splanchnic blood flow. Variceal hemorrhage is associated with increased risk of maternal and fetal mortality. Most documented cases of variceal bleeding in pregnancy report the use of elastic ligation for hemostatic management. Histoacryl glue has become increasingly utilized in the acute management and secondary prophylaxis of gastric and ectopic varices in the general population.AimsEvidence surrounding the use of Histoacryl glue in pregnancy is limited. We report two cases of variceal bleeding during pregnancy managed successfully with glue.MethodsVarices were confirmed endoscopically. Images were obtained and reviewed. Aliquots of injected glue were recorded. Maternal and fetal outcomes were monitored during pregnancy and post-partum.Results Case 1: A 39-year-old G4P3L0, presented at 20 weeks gestation following several episodes of hematemesis. Urgent esophagogastroduodenoscopy (EGD) revealed hyperemia and portal hypertensive gastropathy in the fundus. A gastric varix with high-risk stigmata was injected with a total of 9mL of 50/50 Histoacryl/Lipodol and bleeding stopped. The patient returned to the hospital two weeks following discharge with melena. Repeat EGD showed mild portal hypertensive gastropathy with a clot at the site of the previous bleeding. No further intervention was required, and the patient delivered at 37 weeks via elective caesarian-section. Case 2: A 41-year-old G2P0L1 presented at 26 weeks gestation with severe anemia refractory to five units of blood transfusion. Urgent EGD showed a large gastric varix with recent stigmata of hemorrhage, but no active bleed. A total of 13 mL of 75/50 Histoacryl/Lipidol was injected into the varix with no further bleeding. She delivered by elective caesarian-section at 37 weeks gestation. Repeat EGD performed following delivery showed a larger varix with fresh clot at the inferior portion of the fundus. Due to concern for re-bleeding, a total of 4 mL of 50/50 Histoacryl/Lipidol was injected at the site. CT scan post-partum showed prominent gastric varices with glue visualized within the peripheral branches of the portal vein (Figure 1).ConclusionsOur cases highlight the successful management of gastric varices using Histoacryl glue in pregnancy. Risks associated with Histoacryl glue include glue embolization, local venous thrombosis, as well as extrusion of glue and ulceration. The general complication rate is quoted between 0.5%-5%. One of the two cases was associated with a maternal complication, with evidence of new portal vein thrombosis following injection. The safety of sclerotherapy in pregnancy with cyanoacrylate remains unclear, and further evaluation of the management of gastric varices in this unique population are required. Funding AgenciesNone

A Nomogram for Predicting Portal Hypertensive Gastropathy in Patients With Liver Cirrhosis: A Retrospective Analysis

BackgroundThere is an urgent need for non-invasive methods for predicting portal hypertensive gastropathy (PHG). This study aims to develop and validate a non-invasive method based on clinical parameters for predicting PHG in patients with liver cirrhosis (LC).MethodsThe overall survival (OS) and hepatocellular carcinoma (HCC)-free survival were evaluated in LC patients, both with and without PHG. A prediction model for PHG was then constructed based on a training dataset that contained data on 492 LC patients. The discrimination, calibration, and clinical utility of the predicting nomogram were assessed using the C-index, calibration plot, and decision curve analysis. Internal validation was conducted using a bootstrapping method, and further external validation using data on the 208 other patients.ResultsLC patients with PHG had a worse prognosis compared with those without PHG. A nomogram was constructed using clinical parameters, such as age, hemoglobin content, platelet count and Child-Pugh class. The C-index was 0.773 (95% CI: 0.730–0.816) in the training cohort, 0.761 after bootstrapping and 0.745 (95% CI: 0.673–0.817) in the validation cohort. The AUC values were 0.767, 0.724, and 0.756 in the training, validation and total cohorts, respectively. Well-fitted calibration curves were observed in the training and validation cohorts. Decision curve analysis demonstrated that the nomogram was clinically useful at a threshold of 15%.ConclusionThe nomogram constructed to predict the risk of developing PHG was found to be clinically viable. Furthermore, PHG is an independent risk factor for OS of LC, but not for the occurrence of HCC.

An Audit of more than a Thousand uppergastrointestinal Endoscopy in a Tertiary Care Teaching Hospital in South India

Background: Esophagogastroduodeno (EGD) scopy is a benchmark in the modern era of medicine. It is a sensitive tool used to evaluate the upper gastrointestinal (GI) symptoms. Application of EGDscopy is not merely restricted to diagnosis but as well used for therapeutic purpose. Aim of the Study: To find out the common indications for EGDscopy and its findings in a large tertiary care hospital attached to Bangalore medical college and research institute (BMCRI), Bengaluru. Materials and Methods: A retrospective study was conducted on 1030 patients either admitted or seen on outpatient basis at the Bowring and Lady Curzon hospital attached to BMCRI, Bengaluru with the upper GI symptoms like dyspepsia, dysphagia, epigastric pain abdomen, hematemesis etc from September 2016 to August 2018 and the data was analyzed using appropriate statistical methods. Results: Out of 1030 patients who underwent EGDscopy 62% were male and 61% were 31-59year old. The major indications for EGDscopy were epigastric abdominal pain (18%), dyspepsia (18%), chronic liver disease (15%), dysphagia (11%) and hematemesis (8%). The common pathological findings in the above mentioned indications were gastritis and esophagitis in patient with both epigastric abdominal pain and dyspepsia, portal hypertensive gastropathy and esophageal varices in chronic liver disease, esophageal growth in dysphagia and esophageal varices (EV) in cases of hematemesis. Conclusions: The following insights/observations were made during the course of our study-dysphagia is not just oropharyngeal or esophageal in origin but H. pylori gastritis can cause similar complaints, eradication of which relieves the symptoms in our observation. Chronic abdominal pain associated with postprandial urgency which is deemed as Inflammatory Bowel Disease-Diarrhea (IBS-D) may actually be H. pylori gastritis with exaggerated gastro-colic reflex which gets relieved with anti- H. pylori treatment; further studies are needed to prove this claim. Mosaic like pattern with focal areas of hyperemia in the gastric body mucosa is not just typical of portal hypertensive gastropathy but also can be seen with H. pylori gastritis. Corrosive acid ingestion as a mode of suicidal attempt is common in this part of India which can lead to morbidity and even mortality in severe cases, legislative measures need to be put in place to check the sale and use of corrosive acid. Diffuse white spots in duodenum were mostly due to chronic nonspecific duodenitis rather than intestinal lymphangiectasia in our study.

Frequency and Characteristic of Portal Hypertensive Gastropathy in Liver Cirrhosis Patients

Introduction: Portal hypertensive gastropathy is a term applied to the typical appearance of the mucosa of stomach consisting of a mosaic-like diffuse and reticular cobblestone pattern of gastric mucosal layer secondary to increased blood pressure in the portal vein. Objective: To determine the occurrence and characteristic of portal hypertensive gastropathy in patients with liver cirrhosis Methodology: This study was descriptive cross-sectional piloted at the department of Medicine, Hayatabad medical complex Peshawar for duration of six months from November 2020 to May 2021. A total of 158 patients were observed in our study. All the data was entered and analyzed in SPSS version 21. Results: In our study portal Hypertensive Gastropathy was observed in 34(21.5%) cirrhosis patients while it was not observed in 124(78.5%) patients. Based on the class of portal hypertensive gastropathy, severe and mild types were observed in 43(27.2%) and 115(72.8%) patients respectively. Conclusion: In our study portal hypertensive gastropathy was observed in 34(21.5%) cirrhotic patients, amongst these 27.2% were severe and 72.8% were mild types. In cirrhotic and portal hypertensive gastropathy patients, these findings might have major therapeutic implications. Keywords: Frequency; Portal Hypertensive Gastropathy, Liver cirrhosis

Helicobacter pylori infection is not associated with portal hypertension-related gastrointestinal complications: A meta-analysis.

Despite the importance of Helicobacter pylori infection and portal hypertension (PH)-associated gastrointestinal (GI) diseases, such as esophageal varices and portal hypertensive gastropathy (PHG), the impact of H. pylori infection on PH-related GI complications has not yet been elucidated. This meta-analysis investigated the association between H. pylori infection and the risk of PH-related GI complications. An electronic search for original articles published before May 2020 was performed using PubMed, EMBASE, and the Cochrane Library. Independent reviewers conducted the article screening and data extraction. We used the generic inverse variance method for the meta-analysis, and Begg’s rank correlation test and Egger’s regression test to assess publication bias. A total of 1,148 cases of H. pylori infection and 1,231 uninfected controls were included from 13 studies. H. pylori infection had no significant association with esophageal varices [relative risk (RR) = 0.96, 95% confidence interval (CI) = 0.87–1.06 for all selected studies; RR = 0.95, 95% CI = 0.84–1.07 for cohort studies; odds ratio (OR) = 0.96, 95% CI = 0.60–1.54 for case-control studies]. Although H. pylori infection was significantly associated with PHG in case-control studies [OR = 1.86, 95% CI = 1.17–2.96], no significant differences were found in the cohort studies [RR = 0.98, 95% CI = 0.91–1.05] or all studies combined [RR = 1.18, 95% CI = 0.93–1.52]. In conclusion, H. pylori infection was not associated with the risk of PH-related GI complications. Clinicians should carefully treat cirrhotic patients with PH-related GI complications, regardless of H. pylori infection.

GLUCOGENOSIS AS A CAUSE OF INTRAHEPATIC CHOLESTASIS

Hepatic glycogen storage pathologies are very rare diseases among inborn errors of metabolism caused by the alteration of the enzymes involved in the metabolism of glycogen. GSDs are classified according to enzyme deficiency and affected tissue, including types 0, Ia, Ib, III, IV, VI, and XI. The clinical presentation can be very varied, including intolerance to fasting, growth retardation and hepatomegaly. It can present with hypoglycemia, hyperlactatemia, increased liver enzymes, and hyperlipidemia. The most common type of glycogen storage disease is GDS IX, its incidence is 1: 100,000 births and it is responsible for 25% of all cases. The most common GSD IX subtype is subtype IX a caused by mutations in PHKA2, which accounts for 75% of cases. Long-term complications include liver adenomas, kidney disease, cardiomyopathy, and muscle symptoms. 27-year-old male patient. Important history, positive smoking with IT 1, positive alcoholism with consumption of 8 grams of alcohol per day for 10 years. During childhood, he presented hepatomegaly and an isolated event of jaundice. He began his condition one month before with asthenia, adynamia and weight loss (9 kg / 30 days), accompanied by generalized jaundice, later he presented abdominal pain in the right upper quadrant, with early satiety, acholia and choluria. On physical examination: hepatosplenomegaly, jaundice of the skin and integuments. Paraclinical: BT: 5.3 mg / dl, BD: 1.2 mg / dl 8, DHL: 444IU / L, TGP: 89 U / L, TGO: 168 U / L FA: 1050 U / L. HIV: non-reactive, HBV HCV non-reactive. Ultrasound with multiple nodular echogenic lesions without bile duct dilation, a 1.8 mm common bile duct, a 7 mm portal vein, and an enlarged spleen. Endoscopy: portal hypertensive gastropathy, extrinsic compression of the body and gastric fundus without evidence of varicose veins. Cholangioresonance without intra- and extra-hepatic bile duct dilation. Normal alpha 1 antitrypsin (2.08 g / dl). Given the evidence of intrahepatic cholestasis, it was decided to perform an ultrasound-guided liver biopsy where it was observed positive for intracytoplasmic glycogen in the hepatocytes, thus establishing a definitive diagnosis of Glycogenosis. Due to its low incidence, the diagnostic approach of Glycogenosis presents a challenge. The diagnosis is made at an early age; the clinical data will depend on the affected tissue and type of Glycogenosis. The histopathological report is the mainstay of diagnosis in this type of case and making a differential diagnosis with other entities and a genetic study. Glycogen storage disorders are part of a group of rare and few suspected pathologies. It is not frequent to find them in adult patients due to their complications. The prognosis must be individualized based on the affected tissue and the subtype presented. The authors declare that there is no conflict of interest.

Endoscopic Ultrasound-Guided Portal Pressure Gradient Measurement, Is It Ready for Prime Time?

Portal hypertension is a serious complication of advanced liver disease. Portal pressure gradient measurement accurately determines severity of portal hypertension, prognosis, and guides medical therapy. Conventionally, interventional radiology-guided hepatic venous portal gradient measures portal pressure gradient indirectly using specialized balloon catheter. Recent advances in endoscopy have paved the novel method of endoscopic ultrasound-guided direct portal pressure gradient measurement to evaluate portal hypertension with equivalent safety in both animal models and humans studies. With the expansion of Endo-Hepatology practice, a concept of “one stop shop” is becoming more popular which is a comprehensive endoscopic approach in the evaluation of chronic liver disease. During the same endoscopic procedure, patients could be evaluated for esophageal or gastric varices, portal hypertensive gastropathy, EUS-guided elastography, EUS-guided portal pressure measurement and EUS-guided liver biopsy when suspecting advanced liver disease or diagnosis remains uncertain. This article focuses on the overview of portal hypertension and EUS-guided interventions such as EUS-guided portal pressure measurement, EUS-guided elastography and EUS-guided liver biopsy in the evaluation of individuals with advanced liver disease.

Synergistic antioxidant and anti-inflammatory action of N-acetylcysteine in portal hypertensive gastropathy in rats.

Background and Aim:Portal hypertension (PH) is a syndrome associated with cirrhosis and characterized by a progressive increase in portal pressure, with consequent compensatory vascular dilation. Gastric vascular changes associated with oxidative and nitrosative stress characterize the clinical presentation of portal hypertensive gastropathy (PHG). In addition, the inflammatory process is considered an aggravating factor for severity by contributing to gastric tissue injury. The aim of this study was to investigate the synergistic anti-inflammatory and antioxidant action of N-acetylcysteine (NAC) in the stomach of rats with PH.Materials and Methods:Eighteen Wistar male rats were used in this experimental protocol and were divided into three groups with six in each group: sham-operated (SO), partial portal vein ligation (PPVL), and PPVL + NAC. Treatment with NAC at a dose of 10 mg/kg (i.p.) was initiated on day 8 after surgery and continued for 7 days. We evaluated the expression of iNOS, NQO-1, HSP-90, and SOD by Western blot, as well as nuclear factor-kappa B (NF-κB) and tumor necrosis factor (TNF)-α staining by immunohistochemistry, in the rat stomach.Results:The PPVL group exhibited increased expression of HSP-90, iNOS, SOD, and NQO-1 when compared with controls. NAC reduced the expression of all studied proteins. Similarly, NF-κB and TNF-α staining was increased in PPVL animals versus controls and reduced in PPVL + NAC versus PPVL animals, respectively.Conclusion:These results suggest the effectiveness of NAC as a dual anti-inflammatory and antioxidant in animals with experimental PHG induced by partial ligation of the portal vein.