Computed tomography features of portal hypertensive gastropathy

Imaging of Portal Gastroduodenopathy

Portal hypertension is characterized by elevated pressure in portal venous system due to portal resistance due to various causes. The etiologies are either pre-hepatic, hepatic, or post-hepatic. Elevated portal pressure results in varices at various sites some of which are difficult to identify on endoscopy alone. Other manifestations of elevated portal pressure include portal gastropathy, enteropathy, colopathy, gastric antral vascular ectasia, and ascites. Imaging plays an essential role in diagnosis and imaging of various manifestations of portal hypertension by determining the locations of varices and plan the management for same. Endoscopy helps in visualizing mucosal varices but newer imaging modalities give a panoramic extent of the disease in the entire gastrointestinal tract with great specificity and sensitivity. Initially, Barium study was used to determine esophageal or gastric varices, computed tomography provides detailed anatomic information which can be used to plan management. Due to advancement in imaging and interventional techniques, treatment for varices has seen advent of multiple minimally invasive interventional radiological techniques. A brief outlook on anatomical aspect of varices and various recent advances in management of the same has been provided. Overall knowledge of the various imaging manifestations of portal hypertension can be helpful to evaluate prognosis and plan proper management.

An Update: Portal Hypertensive Gastropathy and Colopathy

Complications of portal hypertension include portal hypertensive gastropathy and colopathy. These disorders may cause chronic or acute gastrointestinal bleeding. The diagnosis is made endoscopically; therefore, there is great variability in their assessment. Portal hypertensive gastropathy can range from a mosaic-like pattern resembling snakeskin mucosa to frankly bleeding petechial lesions. Portal hypertensive colopathy has been less well-described and is variably characterized (erythema, vascular lesions, petechiae). Treatment is challenging and results are inconsistent. Currently, available evidence does not support the use of beta-blockers for primary prevention. Further investigation of the pathogenesis, natural history, and treatment of these disorders is needed.

Portal hypertensive gastropathy and colopathy

Portal hypertensive gastropathy (PHG) and colopathy (PHC) are considered complications of portal hypertension. Both entities are clinically relevant because they may cause insidious blood loss or even acute massive gastrointestinal hemorrhage. Endoscopic evaluation is necessary for the diagnosis of PHG and PHC. The existence of different endoscopic criteria for PHG and PHC makes consensus difficult and results in a broad range of reported prevalence. Therapy targeted at reduction of portal pressure and mucosal blood flow has been used to treat acute bleeding; nonselective β-blockers are the most frequently used agents. Further studies are needed to clarify the natural history, pathogenesis, and treatment of PHG and PHC.

The management of portal hypertensive gastropathy and gastric antral vascular ectasia

Portal hypertensive gastropathy and gastric antral vascular ectasia are gastric mucosal lesions that can cause chronic gastrointestinal haemorrhage and, consequently, chronic anaemia, in patients with cirrhosis. Although chronic anaemia is the most common clinical manifestation, these entities may also lead to acute gastrointestinal bleeding. Despite similar clinical manifestations, their pathophysiology and management are entirely different. Their diagnosis is endoscopic and although generally each of them has a characteristic endoscopic appearance and distribution, there are cases in which the differential is difficult and must rely on histology. This review focuses on the management of both entities. The mainstay of management of portal hypertensive gastropathy is based on portal-hypotensive pharmacological treatment whilst gastric antral vascular ectasia benefits from endoscopic therapy. More invasive options should be reserved for refractory cases.

Portal hypertensive gastropathy: a review

Portal hypertensive gastropathy (PHG) occurs as a complication of cirrhotic or non-cirrhotic portal hypertension. Although the pathogenesis of PHG is not completely understood, evidence suggests that the key factor for the development of PHG is portal hypertension. PHG is clinically important because it may cause acute (and even) massive or insidious, blood loss. The diagnosis of PHG is (only) made endoscopically; it is most often characterized by an abnormality of the gastric mucosa described as a mosaic-like pattern resembling 'snake-skin', with or without red spots and the endoscopic pattern is key its diagnosis. Unfortunately, standardization of the endoscopic diagnostic criteria for PHG is poor and consensus is generally lacking, resulting in a wide range of reported prevalence. Pharmacological therapies, presumably reducing portal pressure and gastric blood flow, have been used to treat acute bleeding; propanolol, a non-selective beta-blocker (24-480 mg/day), has been used most frequently. Endoscopic treatment for PHG bleeding plays a small, if any, role in the treatment of PHG. TIPS and shunt surgery have not been extensively analysed as a treatment for acute or chronic PHG bleeding, but they appear to lessen the severity of PHG. Secondary prophylaxis of PHG bleeding with non-selective beta-blockers is recommended. There is not enough evidence to support the use of beta-blockers in primary prophylaxis of PHG bleeding, even in cases of severe PHG (however, non-selective beta-blockers are recommended if varices are present). Further studies are needed to clarify the role of PHG in suspected chronic gastrointestinal bleeding.

Management of gastropathy and gastric vascular ectasia in portal hypertension

Portal hypertensive gastropathy and gastric antral vascular ectasia may cause gastrointestinal hemorrhage in patients with portal hypertension. Whereas the former presents exclusively in patients with portal hypertension, gastric antral vascular ectasia can also be observed in patients with other conditions. Diagnosis is established with upper gastrointestinal endoscopy, although some cases may require a biopsy to confirm the diagnosis. The most frequent manifestation is ferropenic anemia, which may become transfusion dependent. Treatment in portal hypertensive gastropathy is focused on portal pressure reducing drugs, mainly nonselective beta-blockers, whereas in gastric antral vascular ectasia treatment is based on endoscopic ablation. More invasive options can be used if first-line therapies fail, although these should be evaluated on a case-by-case basis.

Veins around the esophagus and the stomach: do their calibrations provide a diagnostic clue for portal hypertensive gastropathy?

OBJECTIVE

We analyze whether calibrations of esophagogastric veins can be used as an indirect sign for the presence of portal hypertensive gastropathy (PHG).

PATIENTS AND METHODS

The diameters of the left gastric, paraesophageal, and azygos veins were measured on magnetic resonance (MR) portograms of 57 patients with portal hypertension. The mean diameters of the above mentioned veins in patients with and without PHG were compared with Mann-Whitney U test. The diametral associations between the left gastric and azygos veins were assessed with Fisher's exact test in respect to the presence of PHG.

RESULTS

In patients with PHG, the mean diameters of the left gastric, paraesophageal, and azygos veins were not statistically different from those in patients without PHG (P>.05). There was no significant difference in the diametral relationship between the left gastric and azygos veins in patients with and without PHG.

CONCLUSION

The calibrations of the veins around the esophagus and the stomach do not provide any clue about the presence of PHG.

Advances in portal hypertension gastropathy

Portal hypertension gastopathy (PHG) is defined as pathological changes of stomach mucosa, which are accompanied with potral hypertesion, especially in liver cirrhosis patients. The main clinical manifestation is alimentary tract hemorrhage, which may lead to death of patients sometimes. This article aims to review the research advances in the pathogenic mechanism, endoscopic diagnosis, imaging diagnosis and treatment of portal hypertension gastopathy.

Dynamic CT of portal hypertensive gastropathy: significance of transient gastric perfusion defect sign

AIM

To evaluate the "transient gastric perfusion defect" sign as a way of diagnosing portal hypertensive gastropathy (PHG) on multidetector computed tomography (CT).

MATERIALS AND METHODS

Ninety-two consecutive patients with cirrhosis underwent three-phase CT and endoscopy. Endoscopy was performed within 3 days of the CT examination. As controls, 92 patients without clinical evidence of chronic liver diseases who underwent CT and endoscopy were enrolled; the findings at endoscopy were used as a reference standard for patients with PHG. Two radiologists who were unaware of the results of the endoscopy retrospectively interpreted the CT images. PHG was diagnosed on dynamic CT if the transient gastric perfusion defect sign was present. The transient gastric perfusion defect was defined as the presence of transient, segmental or subsegmental hypo-attenuating mucosa in the fundus or body of the stomach on hepatic arterial imaging that returned to normal attenuation on portal venous or equilibrium-phase imaging. The frequency of the transient gastric perfusion defect sign was compared between these two groups using Fisher's exact test. The frequency, sensitivity, specificity, positive predictive values, and negative predictive values of the transient gastric perfusion defect sign were also compared between patients with PHG and without PHG in the cirrhosis group.

RESULTS

Nine patients of 92 patients with cirrhosis were excluded because of previous procedure or motion artifact; the remaining 83 patients with cirrhosis were evaluated. In the cirrhosis group, 40 (48.1%) of 83 patients showed the transient gastric perfusion defect sign. In the control group, none of the 92 patients showed the transient gastric perfusion defect sign. In the cirrhotic group, the frequency of the transient gastric perfusion defect sign was significantly higher in the patients with PHG (75%, 36/48) than in patients without PHG (11.4%, 4/35). The sensitivity, specificity, positive predictive values, and negative predictive values of the sign for CT diagnosis of PHG in the cirrhosis group were 75, 88.6, 90, and 72.1% respectively.

CONCLUSION

The transient gastric perfusion defect sign could be used as a relatively specific sign of PHG in patients with cirrhosis.