Gastric lesions in portal hypertension: inflammatory gastritis or congestive gastropathy?

Mitochondrial Dysfunction by FADDosome Promotes Gastric Mucosal Injury in Portal Hypertensive Gastropathy

Mucosal epithelial death is an essential pathological characteristic of portal hypertensive gastropathy (PHG). FADDosome can regulate mucosal homeostasis by controlling mitochondrial status and cell death. However, it remains ill-defined whether and how the FADDosome is involved in the epithelial death of PHG. The FADDosome formation, mitochondrial dysfunction, glycolysis process and NLRP3 inflammasome activation in PHG from both human sections and mouse models were investigated. NLRP3 wild-type (NLRP3-WT) and NLRP3 knockout (NLRP3-KO) littermate models, critical element inhibitors and cell experiments were utilized. The mechanism underlying FADDosome-regulated mitochondrial dysfunction and epithelial death in PHG was explored. Here, we found that FADD recruited caspase-8 and receptor-interacting serine/threonine-protein kinase 1 (RIPK1) to form the FADDosome to promote Drp1-dependent mitochondrial fission and dysfunction in PHG. Also, FADDosome modulated NOX2 signaling to strengthen Drp1-dependent mitochondrial fission and alter glycolysis as well as enhance mitochondrial reactive oxygen species (mtROS) production. Moreover, due to the dysfunction of electron transport chain (ETC) and alteration of antioxidant enzymes activity, this altered glycolysis also contributed to mtROS production. Subsequently, the enhanced mtROS production induced NLRP3 inflammasome activation to result in the epithelial pyroptosis and mucosal injury in PHG. Thus, the FADDosome-regulated pathways may provide a potential therapeutic target for PHG.

Characteristic endoscopic findings in early-stage autoimmune gastritis

Background and study aims Until recently, autoimmune gastritis (AIG) was usually diagnosed at late stages based on typical endoscopic findings, including corpus-dominant advanced atrophy. Early-stage AIG prior to complete gastric atrophy had rarely been diagnosed due to a lack of knowledge about its endoscopic characteristics. The present study sought to identify the endoscopic characteristics of early-stage AIG, enabling its early diagnosis. Patients and methods The clinical and endoscopic findings of 12 patients diagnosed with early-stage AIG between 2016 and 2021 were retrospectively evaluated. Patients were included if they were: (1) positive for serum anti-parietal cell antibody; (2) diagnosed with histological early-stage AIG; and (3) endoscopically positive for folds on the greater curvature of the gastric corpus. Results Two characteristic endoscopic findings of early-stage AIG were identified: longitudinal alignment of pseudopolyps (i.e., a bamboo joint-like appearance) and swelling of gastric areas with erythema (i.e., a salmon roe-like appearance). Conclusions Endoscopic findings characteristic of early-stage AIG include a bamboo joint-like appearance and a salmon roe-like appearance. Studies in large numbers of patients with long-term follow-up are needed to confirm these findings.

How to suspect the presence of high-risk esophageal varices and when to start endoscopic surveillance in children with biliary atresia?

BACKGROUND AND AIM

Portal hypertension determines the outcome of children with biliary atresia (BA) and is common even after a successful Kasai portoenterostomy (KPE). However, there are no clear-cut guidelines on the age of starting surveillance and the modality (endoscopy vs non-invasive tests [NITs]). In this cohort study, we analyzed our database to find out the utility of NITs in detecting high-risk esophageal varices in BA.

METHODS

From June 2010 to May 2022, consecutive children of BA who underwent upper gastrointestinal (UGI) endoscopy were included. Esophageal varices were classified as high-risk (grade II with red-color signs or grade III or IV irrespective of red-color signs. NITs such as splenomegaly (clinical and USG), platelet count, aspartate transaminase to platelet ratio index (APRI), and platelet-to-spleen diameter ratio were compared between cases with high-risk and low-risk varices.

RESULTS

A total of 110 children, 75 boys (66 successful KPE and 44 failed/KPE not performed) were enrolled. The median age at KPE was 85 days (IQR 63-98). Thirteen (11.8%) children presented with UGI bleeding. The first endoscopy revealed gastroesophageal varices in 75.4% of cases, and 32% of them had high-risk varices. Multivariate analysis revealed failed KPE, history of UGI bleeding, bigger spleen size (> 3.5 cm), lower platelet count (< 150 000), and higher APRI (> 2) are independent predictors of the presence of high-risk esophageal varices.

CONCLUSION

Endoscopy is the best in predicting the presence of high-risk varices that might bleed; hence, early surveillance endoscopy should be started in children with splenomegaly, thrombocytopenia, and high APRI score to prevent variceal bleeding.

The Impact of Partial Splenic Embolization on Portal Hypertensive Gastropathy in Cirrhotic Patients with Portal Hypertension

This study investigated the impact of partial splenic embolization (PSE) on portal hypertensive gastropathy (PHG). We retrospectively analyzed endoscopic findings and the portal venous system of 31 cirrhotic patients with PHG. The improved group was defined as the amelioration of PHG findings using the McCormack classification. Child–Pugh scores of the improved group (18 of 31 patients) were significantly lower compared with those of the non-improved group (p = 0.018). The changes in the diameters of the portal trunk and those of the spleno-portal junction and spleen hilum in the splenic vein of the improved group were significantly larger than those of the non-improved group (p = 0.007, p = 0.025, and p = 0.003, respectively). The changes in the diameters of the portal vein and splenic hilum of the splenic vein showed significant correlations with Child–Pugh score (r = 0.386, p = 0.039; r = 0.510, p = 0.004). In a multivariate analysis of baseline factors related to the improved group, Child–Pugh grade A was significantly associated with the improvement of PHG (odds ratio 6.875, p = 0.033). PSE could be useful for PHG, especially in patients with Child–Pugh grade A, at least in the short term.

The Association of Helicobacter pylori With Portal Hypertensive Gastropathy in Patients With and Without Cirrhosis

INTRODUCTION

Cirrhosis and its associated complication of portal hypertensive gastropathy (PHG), among others, remain a significant cause of death in resource-poor countries with limited capacity for liver transplantation. This research aimed to assess the association of Helicobacter pylori (H. pylori) with portal hypertensive gastropathy and its severity in patients with and without cirrhosis.

METHODOLOGY

The study was conducted at a tertiary care hospital in Pakistan from April 2021 to May 2022. Liver cirrhosis was diagnosed by clinical manifestations, ultrasonography, and laboratory investigations. The severity of liver cirrhosis was assessed using the Child-Pugh scoring system. The association of H. pylori with portal hypertensive gastropathy in patients with and without cirrhosis was assessed using the chi-square test.

RESULTS

A total of 120 patients participated in the study, of which 40 were without liver cirrhosis, while 80 were with cirrhosis. Among patients with cirrhosis, 24 were in Child-Pugh class A, 26 in class B, and 30 in class C. Of patients with liver cirrhosis who were H. pylori-negative, 37.5% (15/40) had portal hypertensive gastropathy. Of these, 12.5% (5/40) had severe PHG, while 25% (10/40) had mild PHG. Of patients with liver cirrhosis who were H. pylori-positive, 62.5% (25/40) had PHG. Of these, 2.5% (1/40) had severe PHG, while 60% (24/40) had mild PHG. Helicobacter pylori contributed nonsignificantly (p=0.080), showing no association with portal hypertensive gastropathy.

CONCLUSION

Helicobacter pylori does not appear to have any significant association to cause or worsen portal hypertensive gastropathy in patients with liver cirrhosis.

Gastric Histopathologic Findings Are Similar in Portal Hypertension Patients With and Without Endoscopic Portal Hypertensive Gastropathy

OBJECTIVES

Portal hypertensive gastropathy (PHG) is a diagnosis made based on endoscopic findings in the appropriate clinical setting. Biopsy may be taken during endoscopy for correlation, but the pathologist may encounter a myriad of nonspecific histologic findings. We undertook this study to evaluate contexts where a histologic diagnosis of PHG might be rendered on biopsy.

METHODS

Two cohorts were established: stomach biopsy specimens from patients with cirrhosis or undergoing varices screening (n = 188) and stomach biopsy specimens with findings interpreted as PHG in the pathology report (n = 29).

RESULTS

In the first cohort, cases with endoscopic varices more frequently displayed foveolar hyperplasia and acute inflammation, with no other histologic differences between cases with and without endoscopic PHG, clinical varices, and clinical cirrhosis. Cases from the second cohort showed no histologic differences when stratified for endoscopic PHG, endoscopic varices, and clinical cirrhosis. Our second cohort displayed the majority of charted histologic findings more frequently than the first. Our results indicate that neither an endoscopic appearance of PHG nor particular clinical diagnoses associated with PHG translate into specific histologic findings.

CONCLUSIONS

Although the histologic findings charted displayed increased frequency in pathology reports with an interpretation of PHG, histology should not be used reliably in the diagnosis of PHG.

CYANOACRYLATE GLUE FOR GASTROESOPHAGEAL VARICES: A SINGLE CENTRE EXPERIENCE FROM NORTH INDIA

BACKGROUND

In natural history of cirrhosis, variceal bleeding is one of the earliest decompensations to happen, and, if adequately managed, survival is improved. Gastric varices have challenges in management due to their location, size and propensity to bleed. The N-butyl 2-cyanoacrylate (NBC) glue application has emerged as definitive therapy in bleeding gastric varices. Here we present our experience with use of NBC in management of gastric and difficult cases of esophageal varices.

METHODS

A total of 75 patients underwent NBC glue application for varices which included 69 patients with gastric varices and six patients with esophageal varices. All the procedures were done with flexible endoscope and sclerotherapy needle after due precautionary measures.

RESULTS

Hemostasis was varices in all patients after endotherapy. The average quantity of glue used was 2.75±0.95 mL. Complete obliteration with single session of NBC application was achieved in 55 patients. Re-bleeding occurred in five patients within 5 days of index event. 20 patients had in-hospital mortality but none was related to gastrointestinal bleeding. 6-week all-cause mortality was 26 (35%).

CONCLUSION

Glue therapy with NBC is a life saving therapy in patients with bleeding gastric varices and esophageal varices not amenable to endoscopic variceal ligation or sclerotherapy.

Two-year risedronate treatment for osteoporosis in patients with esophageal varices: a non-randomized clinical trial

BACKGROUND

Bisphosphonates are the mainstay of osteoporosis treatment, but their use for patients with esophageal varices has been avoided due to the risk of esophagitis, which may cause variceal bleeding. Since most clinical trials assessing osteoporosis treatment last 2-3 years, this study aimed to evaluate a 2-year risedronate treatment for patients with esophageal varices and liver cirrhosis.

METHODS

The study received Institutional Review Board approval, and the sample was divided into two groups according to bone mineral density (BMD). Cirrhosis severity and endoscopic findings at baseline were similar between the groups. The intervention group had 51 patients with osteoporosis, who received oral risedronate 35 mg weekly plus calcium and vitamin D supplements. The control group had 51 patients with osteopenia, receiving only the supplements. Scheduled esophagogastroduodenoscopies and BMD measurements were carried out.

RESULTS

The adjusted esophagitis risk was higher in the intervention group; however, none of the subjects had digestive bleeding. Lumbar spine BMD increased in the intervention group (- 3.06 ± 0.71 to - 2.33 ± 0.90; p < 0.001) and in the control group (- 1.38 ± 0.77 to - 1.10 ± 1.05; p = 0.012). Femoral neck BMD did not change in the intervention group (- 1.64 ± 0.91 to - 1.71 ± 0.95; p = 0.220), but tended to decrease in the control group (- 1.00 ± 0.74 to - 1.09 ± 0.82; p = 0.053).

CONCLUSION

Oral risedronate was effective and did not cause gastrointestinal bleeding in cirrhotic patients with esophageal varices under endoscopic surveillance.

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

Background

There 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).

Methods

The 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.

Results

LC 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%.

Conclusion

The 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.

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

Background and study aims

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.

Results

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.

Conclusion

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.

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. Methods Clinical 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. Results Of 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. Conclusion Esophageal varices, splenomegaly, severe liver cirrhosis, the absence of atrophic gastritis, and etiology were found to be risk factors for PHG in Japanese patients.

Comparison of portal hypertensive gastropathy and gastric antral vascular ectasia: an update

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are two distinct entities that are frequently mistaken with each other, because they present with similar manifestations. This issue may cause catastrophic outcomes, as each one of them has a unique pathophysiology, thereby making their management approaches completely different. There are clinical clues that help physicians distinguish these two. Direct vision via upper endoscopy is often mandatory to establish the diagnosis, and sometimes biopsy is required. In this review, we sought to discuss different aspects of both conditions and highlight clinical evidence that may help in identifying and managing the disease appropriately.

Leaky Gut and Gut-Liver Axis in Liver Cirrhosis: Clinical Studies Update

Portal blood flows into the liver containing the gut microbiome and its products such as endotoxin and bacterial DNA. The cirrhotic liver acts and detoxifies as the initial site of microbial products. In so-called "leaky gut," the increased intestinal permeability for bacteria and their products constitutes an important pathogenetic factor for major complications in patients with liver cirrhosis. Prolonged gastric and small intestinal transit may induce intestinal bacterial overgrowth, a condition in which colonic bacteria translocate into the small gut. Cirrhotic patients further show gut dysbiosis characterized by an overgrowth of potentially pathogenic bacteria and a decrease in autochthonous nonpathogenic bacteria. Pathological bacterial translocation (BT) is a contributing factor in the development of various severe complications. Bile acids (BAs) undergo extensive enterohepatic circulation and play important roles in the gut-liver axis. BT-induced inflammation prevents synthesis of BAs in the liver through inhibition of BA-synthesizing enzyme CYP7A1. A lower abundance of 7α-dehydroxylating gut bacteria leads to decreased conversion of primary to secondary BAs. Decreases in total and secondary BAs may play an important role in the gut dysbiosis characterized by a proinflammatory and toxic gut microbiome inducing BT and endotoxemia, as addressed in my previous reviews. Selective intestinal decontamination by the use of various antimicrobial drugs for management of complications has a long history. Lactobacillus GG decreasing endotoxemia is reported to improve the microbiome with beneficial changes in amino acid, vitamin and secondary BA metabolism. Current approaches for hepatic encephalopathy are the use of nonabsorbable antibiotics and disaccharides. Probiotics may become an additional therapeutic option for advanced liver cirrhosis.

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.

Irsogladine maleate alters expression of a tight junction protein in portal hypertensive gastropathy

BACKGROUND AND AIM

Portal hypertensive gastropathy (PHG) is characterized by noninflammatory edema and vasodilatation of the lamina propria of the mucosal epithelium. In addition, the alterations of intercellular junction proteins and dilatation of the endothelial gaps have been reported. In this study, we examined whether irsogladine maleate (IM), a gastric mucosal protective agent, has the potential to improve PHG by restoration of tight junctions (TJs).

METHODS

Twenty-four patients with PHG were registered and randomly assigned into two groups: 12 patients in the IM-administration group and 12 patients in the non-administration group. In the administration group, IM (4 mg/day) was administered orally for 12 weeks. Gastric mucosa with a red color in patients with PHG were obtained endoscopically on the registration day and 12 weeks later. The endoscopic findings were evaluated, an immunohistochemical analysis of claudin-3 (a TJ protein) expression in gastric mucosal tissues by a laser microscope was performed, and claudin-3 expression was quantified by western blot analysis.

RESULTS

Irsogladine maleate improved the degree of PHG in 2/12 patients endoscopically, in contrast to none of the 12 patients in the non-administration group. Immunohistochemical analysis showed that expression of claudin-3 increased in 8/12 patients in the IM-administration group and 2/12 patients in the non-administration group (P = 0.036). Western blot analysis revealed that the increase in claudin-3 after 12 weeks was significantly higher in the IM-administration group than in the non-administration group (P = 0.010).

CONCLUSIONS

The present pilot study suggested that IM might improve the gastric mucosa in PHG through restoration of TJ-protein claudin-3.

Portal hypertensive vasculopathy - An entity worth remembering with non-neoplastic gastrointestinal lesions

Portal hypertensive vasculopathy (PHV) represents an increase in the pressure in the portal circulation. This increased pressure leads to changes in the mucosa that can be appreciated endoscopically as well as histopathologically. Lesions can be observed in the entire gastrointestinal tract (GIT) including stomach, duodenum, jejunum and colon. The histological changes are appreciated mainly in the mucosal and submucosal blood vessels. A knowledge of these lesions as well as the changes helps in separating them from other close differentials with specific treatment to be instituted. The pathogenesis of the hemodynamic changes is not well-understood. The underlying factor is increased portal pressure. Studies indicate, that besides increased portal pressure other factors in combination led to the observed changes. Portal hypertensive gastropathy (PHG) is seen in the gastric body and fundus, while varices are noted in the cardia and fundus. Changes may be seen in the small intestine and throughout the colon with anorectal varices. Histopathological changes include dilated, congested and ectatic capillaries and edema in the lamina propria besides a large spectrum of other histopathological changes. Mucosal capillaries with thick irregular wall show absence of red blood cells in the lumen. Thickening of the vessel wall serves as a better marker than the vascular diameter when portal hypertension (PHT) is considered. Long standing cases may show fibrosis in lamina propria. At times, these changes may lead to occult gastrointestinal bleeding. Important differentials need to be ruled out in all the cases as the treatment and the outcome of all differs. Endoscopically or histopathologically if the mucosal changes are observed they should not be overlooked and a detailed work-up must be carried out.

Prevalence, nature, and predictors of colonic changes in children with extrahepatic portal vein obstruction

BACKGROUND AND AIMS

The medical literature on colonic changes in children with extrahepatic portal venous obstruction (EHPVO) is limited. We evaluated EHPVO children for prevalence, nature, and relation of colonic changes with disease duration, extent of splenoportal axis (SPA) thrombosis, portal hypertensive gastropathy (PHG), and esophageal varices (EVs). The correlation between histologic and endoscopic changes was studied.

METHODS

Subjects were evaluated by colonoscopy with ileoscopy and biopsy sampling, clinico-laboratory profiles, and SPA imaging. Colonic changes were classified as varices (rectal/colonic) and portal hypertensive colopathy (PHC; colitis-like or vascular lesions). Morphometric analysis of colonic biopsy specimens was performed.

RESULTS

Fifty-four children (median age, 12 years [range, 8-15]; hematochezia in 9 [16.6%]) were evaluated. Rectal and colonic varices were seen in 51 (94%) and 2 (3.7%) cases, respectively. Seventy-five percent of patients had PHC, and colitis-like lesions were more common than vascular lesions (36/40 vs 23/40; P = .001). Colopathy changes were pancolonic in 52.5%, left-sided in 42.5%, and right-sided in 5% of cases. Sixteen percent of patients (8/49) had ileal changes. Children with PHC had PHG more often (90% vs 57%; P = .01), more endotherapy sessions (mean 6 [range, 4-8] vs 2 [range, 1-4]; P = .03), and large EVs less often (12.5% vs 43%; P = .02) than those without colopathy. The extent of SPA thrombosis was similar in patients with and without PHC. The number of capillaries per crypt was higher in EHPVO than in control subjects. Morphometric changes had no correlation with endoscopy.

CONCLUSIONS

Most EHPVO children had colonic changes, and 16% had ileopathy. "Colitis-like" changes and left-side involvement were more common. Patients with PHG and eradicated EVs had a higher risk of PHC.

Safety and efficacy of risedronate for patients with esophageal varices and liver cirrhosis: a non-randomized clinical trial

Despite the high prevalence of osteoporosis in liver cirrhosis, the indication of bisphosphonates for patients with esophageal varices has been avoided due to risk of digestive mucosal damage. Therefore, this study aimed to evaluate the safety profile of risedronate treatment for patients with osteoporosis, liver cirrhosis and esophageal varices with low risk of bleeding. A total of 120 patients were allocated into two groups according to their bone mineral density measured by dual-energy X-ray absorptiometry. In the intervention group, 57 subjects with osteoporosis received oral risedronate at 35 mg weekly plus daily calcium and vitamin D supplementation. In the control group, 63 subjects with osteopenia received only calcium and vitamin D. The groups received the treatment for one year and underwent surveillance endoscopies at six and 12 months, as well as a control dual-energy X-ray absorptiometry after a 12-month follow-up. The study received Institutional Review Board approval. The groups had not only comparable Model for End-stage Liver Disease score and esophageal varices degree, but also similar incidence of digestive adverse effects. A significant improvement was achieved in the intervention group in the lumbar spine T score (p < 0.001). The results suggest that risedronate may be safely used in liver cirrhosis and esophageal varices with low bleeding risk under endoscopic surveillance, thus allowing bone mass recovery.

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.

IL-6-driven FasL promotes NF-κBp65/PUMA-mediated apoptosis in portal hypertensive gastropathy

Mucosal epithelial apoptosis with non-specific inflammation is an essential pathological characteristic in portal hypertensive gastropathy (PHG). However, whether a coordinated crosstalk between myeloid cells and epithelial cells involved in PHG remains unclear. IL-6, which is induced in the mucosa of PHG patients and mice, promotes FasL production via enhancing NF-κBp65 activation in myeloid cells, while blockage of IL-6 signaling by Tocilizumab or deletion of NF-κBp65 in myeloid cells attenuates the inflammatory response and Fas/FasL-mediated epithelial apoptosis in PHG. IL-6-driven FasL from myeloid cells combines with epithelial Fas receptor to encourage NF-κBp65/PUMA-mediated epithelial apoptosis in PHG, and inhibition of NF-κBp65 or knockout of PUMA alleviates Fas/FasL-mediated epithelial apoptosis in PHG. These results indicate that IL-6 drives FasL generation via NF-κBp65 in myeloid cells to promote Fas/NF-κBp65/PUMA-mediated epithelial apoptosis in PHG, and this coordinated crosstalk between myeloid cells and epithelial cells may provide a potential therapeutic target for PHG.

Management of a Portal Hypertensive Polyp: Case Report of a Rare Entity

Portal hypertensive polyposis is a rare finding represented in about 2.5% of all patients with portal hypertension. The diagnostic criteria are not yet clearly defined. It has been mentioned in a few case reports; its distribution was mainly duodenal and less frequently gastric. Here, a patient with type 2 diabetes and liver cirrhosis was hospitalized for vomiting, abdominal pain, and melena. The patient was admitted to the intensive care unit for stabilization and urgent esophagogastroduodenoscopy (EGD). EGD revealed a single antral polyp occluding the pyloric ring which was the cause of gastric outlet obstruction. Complete debulking by argon plasma was done which improved gastric outlet obstruction and melena. We conclude that argon plasma coagulation is a safe, rapid, and effective method for treating portal hypertensive polyposis.

Prevalence of Portal Hypertensive Gastropathy in Chronic Liver Disease and Correlation with the Severity of Liver disease

Background Portal hypertensive gastropathy (PHG) is an underappreciated condition in patients with chronic liver disease (CLD). It is a common endoscopic finding in CLD patients, but its relation with esophageal varices (EV) and the severity of the liver disease is controversial. Herein, we aimed to study the prevalence of PHG in CLD patients and to determine its association with EV and the severity of the liver disease. Methods This descriptive, cross-sectional, analytical study was conducted at the Hepatology department, Bir Hospital Kathmandu from 19^th March to 30^th June 2019. A total of 404 patients with CLD of various etiology fulfilling the inclusion criteria were approached, and informed consent was taken before enrolling in the study. All patients underwent EGD, and the findings related to EV and PHG were noted. The severity of PHG was graded according to the McCormack classification and EV were graded according to the American Association for the study of liver diseases guideline. The severity of liver disease was stratified based on Child-Pugh class and Model for End-Stage Liver Disease (MELD score). Data was entered on Statistical Package for the Social Sciences (SPSS) Version 25 for further analysis. Results Of 404 CLD patients, the mean (±SD) age was 49.14 (±10.5) years. Portal hypertensive gastropathy was observed in 269 (66.6%) patients, of which 80.6% (217) had mild PHG while 19.4% (52) had severe PHG. EV were present in 362 (89.6%) patients. One hundred and thirty-two (36.5%) had small EV, and 230 (63.5%) had large EV. No significant association was observed between grades of gastropathy and size of varices (p = 0.36). There was a non-significant association with the MELD score and other biochemical parameters. However, there were significant associations between Child-Pugh class and PHG and Child-Pugh class and PHG severity, p = 0.001 and p = 0.01 (p <0.05), respectively. Conclusions In our study, the prevalence of PHG in the Nepalese population in CLD is 66.6 %. PHG is significantly associated with the severity of CLD in terms of Child-Pugh class but not associated with MELD. Also, no association has been found with the size of varices.

Utility of histology for the diagnosis of portal hypertensive gastroenteropathy. Concordance between the endoscopic image and gastrointestinal biopsies. Role of the CD34 marker

INTRODUCTION

Upper gastroscopy in patients with cirrhosis often reveals non-specific lesions, which are usually oriented as portal hypertensive gastropathy (PHG). However, the diagnosis of PHG can be difficult, both from an endoscopic and histological point of view. The study of CD34 expression, which enhances the endothelial cells of the microvasculature, could help the differential diagnosis. The objectives of this study were to evaluate the correlation between endoscopy and histology in the diagnosis of PHG and to assess the utility of CD34 in the diagnosis of PHG.

MATERIAL AND METHODS

The results of immunostaining with CD34 gastric fundus biopsies from 100 cirrhotic patients and 20 controls were compared with the endoscopic images.

RESULTS

The correlation between the histology and the endoscopic diagnosis of PHG was very low (kappa=0.15). In addition, the measurement of the diameter of the gastric vessels enhanced by the use of immunohistochemical staining (CD34) did not show good correlation with the endoscopic diagnosis (p=.26) and did not provide relevant information for the histological diagnosis of PHG either.

DISCUSSION

The correlation between histology and endoscopy is low for the diagnosis of PHG. The use of immunostaining for CD34 does not seem to improve the diagnostic yield of the histological study.

Utility of histology for the diagnosis of portal hypertensive gastroenteropathy. Concordance between the endoscopic image and gastrointestinal biopsies. Role of the CD34 marker

INTRODUCTION

Upper gastroscopy in patients with cirrhosis often reveals non-specific lesions, which are usually oriented as portal hypertensive gastropathy (PHG). However, the diagnosis of PHG can be difficult, both from an endoscopic and histological point of view. The study of CD34 expression, which enhances the endothelial cells of the microvasculature, could help the differential diagnosis. The objectives of this study were to evaluate the correlation between endoscopy and histology in the diagnosis of PHG and to assess the utility of CD34 in the diagnosis of PHG.

MATERIAL AND METHODS

The results of immunostaining with CD34 gastric fundus biopsies from 100 cirrhotic patients and 20 controls were compared with the endoscopic images.

RESULTS

The correlation between the histology and the endoscopic diagnosis of PHG was very low (kappa=0.15). In addition, the measurement of the diameter of the gastric vessels enhanced by the use of immunohistochemical staining (CD34) did not show good correlation with the endoscopic diagnosis (p=.26) and did not provide relevant information for the histological diagnosis of PHG either.

DISCUSSION

The correlation between histology and endoscopy is low for the diagnosis of PHG. The use of immunostaining for CD34 does not seem to improve the diagnostic yield of the histological study.

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

BACKGROUND/AIMS

To evaluate patients with portal hypertension (PH) of varied etiologies for portal hypertensive enteropathy (PHE) using the PillCam SB3 capsule endoscopy (CE) system.

METHODS

Consecutive 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.

RESULTS

Of 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.

CONCLUSION

The 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.

Blood Ammonia Level Correlates with Severity of Cirrhotic Portal Hypertensive Gastropathy

Background

Portal hypertensive gastropathy (PHG) is a common anomaly with potential for bleeding found in portal hypertension. Blood ammonia levels correlate well with liver disease severity and existence of portosystemic shunts. Increased ammonia results in vasodilation and hepatic stellate cell activation causing and exacerbating portal hypertension.

Objective

To assess the relation of blood ammonia to the presence and severity of portal hypertensive gastropathy in cirrhosis.

Methods

This cross-sectional study included 381 cirrhotics undergoing screening for esophageal varices (EV) divided into a portal hypertensive gastropathy group (203 patients with EV and PHG), esophageal varix group (41 patients with EV but no PHG), and control group (137 patients with no EV or PHG). A full clinical examination, routine laboratory tests, abdominal ultrasonography, child score calculation, and blood ammonia measurement were performed for all patients.

Results

Blood ammonia, portal vein, splenic vein, and splenic longitudinal diameters were significantly higher and platelet counts lower in patients with EV and EV with PHG than controls. Patients having EV with PHG had significantly higher bilirubin and ammonia than those with EV but no PHG. Severe PHG was associated with significantly higher ammonia, EV grades, and superior location and a lower splenic longitudinal diameter than mild PHG. The PHG score showed a positive correlation with blood ammonia and a negative correlation with splenic longitudinal diameter.

Conclusions

Blood ammonia levels correlate with the presence, severity, and score of portal hypertensive gastropathy in cirrhosis suggesting a causal relationship and encouraging trials of ammonia-lowering treatments for the management of severe PHG with a tendency to bleed.

The therapeutic effect of splenectomy plus selective pericardial devascularization versus conventional pericardial devascularization on portal hypertension in China: a meta-analysis

Background

To systematically review perioperative outcomes and postoperative complications between splenectomy plus s-EGDV and n-sEGDV for portal hypertension complicated with thoracic esophageal varices and bleeding by a meta-analysis.

Method

We searched the databases of PubMed, the Cochrane Library, Web of Science, EMBASE, TCGA, Chinese Biomedicine Database from January 2000 to June 2017, and included studies that compared perioperative outcomes and postoperative complications between s-EGDV and n-sEGDV. These included studies were assessed by two independent investigators.

Results

Seven randomized controlled trials (RCTs) and seven non-randomized observational clinical studies (OCS) were included. The s-EGDV was more beneficial than n-sEGDV in reducing the PVF (OR = 4.26; 95% CI, 2.81–5.71; P < 0.00001; I² = 97% for heterogeneity), portal vein flow (OR = −111.75; 95% CI, −197.13–26.38; P = 0.01; I² = 90% for heterogeneity), portal hypertensive gastropathy(OR = 0.38; 95% CI, 0.28–0.51; P < 0.00001; I² = 0% for heterogeneity), hepatic encephalopathy (OR = 0.40; 95% CI, 0.23–0.71; P = 0.002; I² = 22% for heterogeneity), postoperative re-bleeding (OR = 0.43; 95% CI, 0.29–0.63; P < 0.0001; I² = 9% for heterogeneity), postoperative mortality (OR = 0.52; 95% CI, 0.32–0.85; P = 0.009; I² = 0% for heterogeneity) and in increasing hepatic artery flow (OR = 92.53; 95% CI, 9.60–175.46; P = 0.03; I² = 95% for heterogeneity).

Conclusion

sEGDV offers a more effective surgical approach with fewer complications to treat portal hypertension than n-sEGDV. Upon further detailed analysis of the surgical indications and hemodynamic and postoperative major complications of selective devascularization, sEGDV likely will provide us with a new direction in the choice of surgical approach for portal hypertension.

Elevated Gastric Antrum Erosions in Portal Hypertension Patients: Peptic Disease or Mucosal Congestion?

Background/Aims

Portal hypertension (PH) is a syndrome characterized by chronic increase in the pressure gradient between the portal vein and inferior vena cava. Previous studies have suggested an increased frequency of antral elevated erosive gastritis in patients with PH, as well as an etiologic association; however, there has not been any histological evidence of this hypothesis to date. Our aim was to evaluate the histological features found in elevated antral erosions in patients with portal hypertension.

Methods

Sixty-nine patients were included; 28 with and 41 without PH. All patients underwent endoscopy, and areas with elevated antral erosion were biopsied.

Results

In the PH group, 24 patients had inflammatory infiltration with or without edema and vascular congestion, and 4 patients had no inflammation. In the group without PH, all patients showed inflammatory infiltration of variable intensity. There was no statistical significance between the two groups in the presence of Helicobacter pylori. There as a histological similarity between the two groups, if PH patients without inflammation were excluded; however, more edema and vascular congestion were observed in the PH group (p=0.002).

Conclusions

The findings show that elevated antral erosions in patients with PH have more evident edema and vascular congestion in addition to lymphocytic infiltration.

Iron deficiency anemia in chronic liver disease: etiopathogenesis, diagnosis and treatment

Chronic liver disease is accompanied by multiple hematological abnormalities. Iron deficiency anemia is a frequent complication of advanced liver disease. The etiology is multifactorial, mostly due to chronic hemorrhage into the gastrointestinal tract. The diagnosis of iron deficiency anemia is very challenging, as simple laboratory methods, including serum iron, ferritin, transferrin saturation (Tsat), and mean corpuscular volume are affected by the liver disease itself or the cause of the disease, resulting in difficulty in the interpretation of the results. Several new parameters, such as red blood cell ferritin, serum transferrin receptor test and index, and hepcidin, have been studied for their utility in indicating true iron deficiency in combination with chronic liver disease. Once iron deficiency anemia is diagnosed, it should be treated with oral or parenteral iron as well as portal pressure reducing drugs. Blood transfusion is reserved for symptomatic anemia despite iron supplementation.

PGE2 /EP4 receptor attenuated mucosal injury via β-arrestin1/Src/EGFR-mediated proliferation in portal hypertensive gastropathy

BACKGROUND AND PURPOSE

Portal hypertensive gastropathy (PHG) is a serious complication of liver cirrhosis and a potential cause of bleeding in patients with cirrhosis. Suppressed mucosal epithelial proliferation is a crucial pathological characteristic of PHG. Our studies demonstrated an important role for PGE₂ and its EP₄ receptor in the promotion of mucosal proliferation. However, whether β-arrestin1 (β-arr1), a well-established mediator of GPCRs, is involved in the PGE₂ /EP₄ receptor-mediated mucosal proliferation complex in PHG remains unclear. The aim of the study was to investigate whether β-arr1 participated in PGE₂ /EP₄ receptor-mediated mucosal proliferation by recruiting the Src/EGF receptor (EGFR) complex to activate Akt/proliferating cell nuclear antigen (PCNA) signalling in PHG.

EXPERIMENTAL APPROACH

Gastric mucosal proliferation was examined in patients with PHG and the PHG model of β-arr1-knockout (β-arr1-KO) and β-arr1-wild type (β-arr1-WT) mice. The induction of β-arr1 and EP₄ receptor expression and the Src/EGFR signalling elements was investigated, and the mechanisms underlying PGE₂ -regulated gastric mucosal proliferation were analysed.

KEY RESULTS

Portal hypertension suppressed COX-1 but not COX-2, which was accompanied by a down-regulation of PGE₂ generation and EP₄ receptor levels in the mucosa of patients with PHG. PGE₂ administration markedly promoted mucosal proliferation in a mouse model of PHG. Targeted deletion of β-arr1 abolished PGE₂ /EP₄ receptor-mediated gastric proliferation in PHG by repressing the Src/EGFR/Akt/PCNA signalling network.

CONCLUSIONS AND IMPLICATIONS

These results indicate that β-arr1 regulates PGE₂ /EP₄ receptor-mediated mucosal proliferation by promoting activation of the Src/EGFR/Akt/PCNA signalling pathway, and thus, this network is a potential therapeutic target for PHG.

Endoscopic Variceal Ligation followed by Argon Plasma Coagulation Against Endoscopic Variceal Ligation Alone: A Randomized Controlled Trial

GOALS

Our aim was to study the efficacy and the safety of argon plasma coagulation (APC) in secondary prophylaxis against esophageal varices in view of many contraindications and side effects to β-blockers in cirrhotic patients.

BACKGROUND

Rebleeding rates from esophageal varices after endoscopic variceal ligation (EVL) are high; thus, the current recommendation is to combine nonselective β-blockers to it, but side effects and relative contraindications to nonselective β-blockers hinder their usage or require discontinuation in 15% to 20% of the cirrhotic patients. Thus, it is important to find another combination.

STUDY

This study included all patients admitted to the Alexandria Main University Hospital during the period between April 2012 and October 2012 with variceal bleeding. After exclusions, the total number of included patients was 40. All participants were subjected to EVL and eradication of varices, and then they were randomized to either APC (group 1) or just observation (group 2). Both groups were followed up by endoscopy every 3 months for 30 months.

RESULTS

During the 2.5-year follow-up, 21% of the participants in group 1 experienced esophageal variceal recurrence, but no one needed rebanding. In group 2, 68.4% of the participants experienced esophageal variceal recurrence (P=0.003) and 63.2% underwent rebanding (P<0.001).

CONCLUSIONS

APC after esophageal variceal eradication using EVL can decrease the risk of recurrence of esophageal varices and the need for rebanding. This technique may be recommended in secondary prophylaxis against esophageal variceal bleeding in those who have contraindications, are intolerant, or are noncompliant to nonselective β-blockers.

Spectrum of small-bowel mucosal abnormalities identified by capsule endoscopy in patients with portal hypertension of varied etiology

BACKGROUND

Bleeding from small intestinal ectopic varices and persistent anemia caused by portal hypertensive enteropathy (PHE) can be very challenging. Capsule endoscopy (CE) is one of the best noninvasive modalities in identifying such lesions.

AIM

The aims of this study are to study the prevalence of small-bowel changes related to portal hypertension (PHT) and to correlate them with the observations related to the effects of portal hypertension in the esophagus, stomach, and colon.

METHODS

Thirty-two patients with various etiologies of PHT with either anemia or gastrointestinal bleed were included along with age- and sex-matched controls without PHT. All patients underwent blood tests, gastroscopy, colonoscopy, and CE. The small-bowel findings by CE were categorized as inflammatory-like and vascular lesions. The small-bowel changes were analyzed to find out any association with various demographic, clinical, and endoscopic variables.

RESULTS

Thirty-one out of 32 patients with PHT (96.8%) had PHE identified by CE. Of them, 31 (96.8%) had inflammatory-like appearance, 11 (34.4%) had vascular lesions, and 2 (6.2%) had small-bowel varices. Inflammatory-like appearance was noted in eight (25%) and angiodysplastic lesions in two (6.2%) controls. Findings compatible with PHE were detected in 96.8% of the patients and 25% of the controls (X ² =34.72, p=0.000).The presence of PHE was not associated with any of the above-mentioned variables.

CONCLUSIONS

Small-bowel mucosal changes were seen in significantly higher number of patients with PHT with anemia.

Efficacy of argon plasma coagulation in the management of portal hypertensive gastropathy

Objectives: Evaluation of the outcome and experience in 2 years of management of portal hypertensive gastropathy (PHG) by argon plasma coagulation (APC) in a cohort of Egyptian cirrhotic patients. Methods: This study was conducted over a 2-year period from January 2011 to February 2013. Upper gastrointestinal endoscopy was performed to evaluate the degree and site of PHG. APC was applied to areas with mucosal vascular lesions. Results: In total, 200 cirrhotic patients were enrolled; 12 patients were excluded due to death (n = 6) caused by hepatic encephalopathy (n = 3), hepatorenal syndrome (n = 2), or chronic lymphatic leukemia (n = 1), or did not complete the treatment sessions (n = 6), so 188 patients completed the study. PHG was mainly fundic in 73 patients (38.8 %), corporeal in 66 patients (35.1 %), and pangastric in 49 patients (26.1 %) (P = 0.026). Patients were exposed to APC and received proton pump inhibitors together with propranolol at a dose sufficient to reduce the heart rate by 25 % or down to 55 beats/min. The mean (± standard deviation) number of sessions was 1.65 ± 0.8; six patients needed four sessions (3.2 %), 19 patients needed three sessions (10.1 %), 74 patients needed two sessions (39.4 %), and 89 patients needed one session (47.3 %). Patients with fundic and corporeal PHG required the lowest number of sessions (P = 0.000). Patients were followed up every 2 months for up to 1 year; the end point was a complete response with improved anemia and blood transfusion requirement which was achieved after one session in 89 patients (75.4 %), two sessions in 24 patients (20.3 %) and three sessions in five patients (4.3 %). A complete response was more prevalent in patients with corporeal and fundic PHG (P = 0.04). Conclusions: After 2 years' experience in managing PHG, we found that a combination of APC and non-selective beta blockers was highly efficacious and safe in controlling bleeding from PHG. In addition, APC alone is rapid, and effective in the control of PHG induced bleeding, especially when beta blockers are contraindicated.

Hemodynamic effect of the left gastric artery on esophageal varices in patients with cirrhosis

BACKGROUND

To examine the hemodynamic effect of the left gastric artery (LGA) on the esophageal varices (EV) in cirrhosis.

METHODS

This was a prospective study performed in 48 cirrhosis patients (35 men, 13 women; median age 61.6 ± 11.3 years, range 38-83 years) with EV (medium 35, large 13), who underwent selective LGA angiography, hepatic venous catheterization, endoscopic ultrasonography (EUS) and Doppler ultrasonography before endoscopic treatment for EV. Angiographic findings including diameter of the main trunk, detection time of EV, and mild/severe degree of peripheral staining were assessed. The median period of post-treatment observation was 17.1 months.

RESULTS

LGA angiograms were successfully obtained in 45/48 patients. EV were demonstrated in 45/45 patients, with a mean detection time of 6.9 s (2-21), which was longer in patients with variceal recurrence (7.0 s) than in those without (5.6 s, P = 0.480). The staining was mild in 25 patients (55.6 %) and severe in 20 patients (44.4 %), and portal hypertensive gastropathy was more frequent in the latter (13/20, 65.0 %) than in the former (7/25, 28.0 %, P = 0.013). Multivariate analysis showed that pre-treatment detection time (P = 0.04) and post-treatment submucosal vascular area at the cardia wall by EUS (P = 0.036) were significant factors for variceal recurrence. No other factors, including hepatic venous pressure gradient and Doppler parameters, showed significant relationships with the variceal recurrence.

CONCLUSIONS

The hemodynamics in the LGA may act as an initiator of variceal formation, showing close linkage with variceal recurrence, and independent of portal pressure.

Portal hypertensive gastropathy as a prognostic index in patients with liver cirrhosis

BACKGROUND

Portal hypertensive gastropathy (PHG) is a frequently overlooked complication of liver cirrhosis (LC). The clinical implications of PHG as a prognostic factor of LC or a predictive factor for the development of hepatocellular carcinoma (HCC) have not been established. The aim of this study was to assess the clinical significance of PHG in patients with LC.

METHODS

Patients with LC were prospectively enrolled and followed in a single tertiary hospital in the Republic of Korea. Baseline hepatic vein pressure gradient (HVPG) was measured, and esophagogastroduodenoscopy (EGD) was performed. The associations of PHG with HVPG, survival and the development of HCC were evaluated.

RESULTS

A total of 587 patients were enrolled. The mortality rate was 20.3 % (n = 119), and HCC developed in 9.2 % (n = 54) during the follow-up period (32.6 ± 27.8 months). The grade of PHG was well correlated with HVPG (no PGH: median 9.2 [IQR: 7.2-16.7], mild PHG: 14.6 [10.1-19.3], and severe PHG: 17.3 [12.3-21.5], P < 0.001), as well as with Child-Pugh class, MELD score or survival. However, it was not associated with the development of HCC. The grade of PHG (HR 3.29, 95 % CI: 1.12-9.63, severe vs. no PHG) and Child-Pugh class (HR 3.53, 95 % CI: 1.79-6.97, Child C vs A) showed significant associations with mortality.

CONCLUSION

PHG was well correlated with portal hypertension and could be used as a prognostic factor for LC but not for the prediction of HCC.

Non-Invasive Diagnosis of Portal Hypertensive Gastropathy: Quantitative Analysis of Microbubble-Induced Stomach Wall Enhancement

The aim of the study described here was to elucidate the efficacy of contrast-enhanced ultrasound (CEUS) prospectively as a tool in the diagnosis of portal hypertensive gastropathy (PHG). The peak enhancement time at the upper stomach wall (PT) and intensity ratio at the upper stomach/the spleen (IR) between pre- and peak enhancement were evaluated by CEUS with perflubutane microbubble agent in 56 patients, 42 with cirrhosis (16 with PHG) and 14 controls. The IR was higher in patients with PHG (1.21 ± 0.11) than in those without (0.91 ± 0.15, p < 0.05) and the controls (0.78 ± 0.11, p < 0.01), although PT did not differ between these groups. The area under the receiver operating characteristic curve for IR was 0.8199 in the presence of PHG, with the best cutoff value of 0.94, sensitivity 65.9%, specificity 72.6%, positive predictive value 62.2%, negative predictive value 73.1% and accuracy 70.4%. CEUS may have potential as a less invasive tool for diagnosis of PHG in patients with cirrhosis.

The spectrum of gastric pathology in portal hypertension-An endoscopic and pathologic study of 550 cases

One of the main tasks for pathologists when evaluating gastric biopsies from patients with portal hypertensive gastropathy (PHG) is to examine whether there is increased mucosal vasculature as suggested by endoscopy. However, the full spectrum of pathology findings in patients with portal hypertension (pHTN) is largely unknown. We systematically characterized the endoscopic and pathologic features in gastric biopsies from pHTN patients (study group) and compared with those from patients without pHTN (control group). The study group consisted of 550 consecutive surveillance esophagogastroduodenoscopic (EGD) biopsies, whereas the control group included 281 consecutive EGD biopsies for a variety of indications. As expected, the endoscopic prevalence of PHG was 28%, among which two-thirds showed corresponding histopathologic evidence of increased vasculature. However, non-Helicobacter pylori gastritis was the most common finding in pHTN patients on histology (40%). In addition, hyperplastic polyp was also more common in pHTN patients than in controls (6% vs 3%; P=0.0314). In contrast, pathology findings of nonspecific reactive changes (29% vs 51%; P<0.0001), proton pump inhibitor-related changes (16% vs 30%; P<0.0001), and malignancy (1% vs 3%; P=0.0138) were less common in pHTN patients. Our results show a spectrum of gastric endoscopic and pathologic findings in pHTN patients. The predominant gastric pathology in pHTN patients may be associated with pHTN-induced gastric microcirculation impairment.

Portal hypertensive gastropathy with a focus on management

Portal hypertensive gastropathy (PHG) is a painless condition of gastric mucosal ectasia and impaired mucosal defense, commonly seen in patients with elevated portal pressures. While it is typically asymptomatic and incidentally discovered on upper endoscopy, acute and chronic bleeding may occur. There are no definitive recommendations for treatment of asymptomatic PHG. Non-selective β-blockers represent the mainstay of therapy for chronic bleeding, while somatostatin and vasopressin and their derivatives may be used in conjunction with supportive measures for acute bleeding. Salvage therapy with transjugular intrahepatic portosystemic shunt or rarely surgical shunt is appropriate when medical management fails. The role of endoscopic therapy for PHG is controversial. Liver transplantation should be considered as a final resort in cases of refractory bleeding due to PHG.

Changes of Intestinal Functions in Liver Cirrhosis

Background

Understanding of the gut-liver axis is important for the up-to-date management of liver cirrhosis, and changes of intestinal functions form the core of this interesting research field.

Summary

Most investigators noted small intestinal dysmotility in their patients with liver cirrhosis. Marked changes in the contraction pattern were observed in early manometric studies. The orocecal transit time, particularly small intestinal transit, has generally been reported to be prolonged, which has been demonstrated in multiple investigations to be related to the severity of the liver disease (e.g., Child-Pugh class), the presence of small intestinal bacterial overgrowth (SIBO) and hepatic encephalopathy (HE) as well as a history of spontaneous bacterial peritonitis. Bacteriologically proven SIBO in proximal jejunal aspiration has been reported to be present in up to 59% of cirrhotic patients and is associated with systemic endotoxemia. Clinical and experimental studies suggest that delayed small bowel transit in liver cirrhosis may lead to SIBO, which could contribute to the symptoms of abdominal pain and diarrhea. In addition to autonomic neuropathy, metabolic derangements and diabetic state, SIBO itself may delay intestinal transit in cirrhotic patients. Several studies, both from the West and the East, have shown that the gut microbiota is altered in cirrhotic patients and particularly those with HE. Further, a quantitative change in Bacteroides/Firmicutes ratio, with a prevalence of potentially pathogenic bacteria (e.g., Enterobacteriaceae) and reduction in specific commensals (e.g., Lachnospiraceae), has been described. Structural and functional changes in the intestinal mucosa that contribute to increases in intestinal permeability for bacteria and their products have been observed in patients with liver cirrhosis, which is considered as an important pathogenetic factor for several complications. The mechanism of intestinal barrier dysfunction in cirrhosis is multifactorial, including alcohol, portal hypertension (vascular congestion and dysregulation), endotoxemia, SIBO, local inflammation and, most likely, immunological factors and medications.

Key Messages

This review summarizes major achievements regarding intestinal dysfunction in cirrhosis for future gastroenterology research. The question of whether this intestinal barrier dysfunction is accompanied and/or at least partly caused by structural and functional changes in the epithelial tight junction proteins is as yet unsolved. Development of new strategies to modulate gut-liver interaction is urgently needed.

Changes of Intestinal Functions in Liver Cirrhosis

BACKGROUND

Understanding of the gut-liver axis is important for the up-to-date management of liver cirrhosis, and changes of intestinal functions form the core of this interesting research field.

SUMMARY

Most investigators noted small intestinal dysmotility in their patients with liver cirrhosis. Marked changes in the contraction pattern were observed in early manometric studies. The orocecal transit time, particularly small intestinal transit, has generally been reported to be prolonged, which has been demonstrated in multiple investigations to be related to the severity of the liver disease (e.g., Child-Pugh class), the presence of small intestinal bacterial overgrowth (SIBO) and hepatic encephalopathy (HE) as well as a history of spontaneous bacterial peritonitis. Bacteriologically proven SIBO in proximal jejunal aspiration has been reported to be present in up to 59% of cirrhotic patients and is associated with systemic endotoxemia. Clinical and experimental studies suggest that delayed small bowel transit in liver cirrhosis may lead to SIBO, which could contribute to the symptoms of abdominal pain and diarrhea. In addition to autonomic neuropathy, metabolic derangements and diabetic state, SIBO itself may delay intestinal transit in cirrhotic patients. Several studies, both from the West and the East, have shown that the gut microbiota is altered in cirrhotic patients and particularly those with HE. Further, a quantitative change in Bacteroides/Firmicutes ratio, with a prevalence of potentially pathogenic bacteria (e.g., Enterobacteriaceae) and reduction in specific commensals (e.g., Lachnospiraceae), has been described. Structural and functional changes in the intestinal mucosa that contribute to increases in intestinal permeability for bacteria and their products have been observed in patients with liver cirrhosis, which is considered as an important pathogenetic factor for several complications. The mechanism of intestinal barrier dysfunction in cirrhosis is multifactorial, including alcohol, portal hypertension (vascular congestion and dysregulation), endotoxemia, SIBO, local inflammation and, most likely, immunological factors and medications.

KEY MESSAGES

This review summarizes major achievements regarding intestinal dysfunction in cirrhosis for future gastroenterology research. The question of whether this intestinal barrier dysfunction is accompanied and/or at least partly caused by structural and functional changes in the epithelial tight junction proteins is as yet unsolved. Development of new strategies to modulate gut-liver interaction is urgently needed.

Changes of Intestinal Functions in Liver Cirrhosis

Background

Understanding of the gut-liver axis is important for the up-to-date management of liver cirrhosis, and changes of intestinal functions form the core of this interesting research field.

Summary

Most investigators noted small intestinal dysmotility in their patients with liver cirrhosis. Marked changes in the contraction pattern were observed in early manometric studies. The orocecal transit time, particularly small intestinal transit, has generally been reported to be prolonged, which has been demonstrated in multiple investigations to be related to the severity of the liver disease (e.g., Child-Pugh class), the presence of small intestinal bacterial overgrowth (SIBO) and hepatic encephalopathy (HE) as well as a history of spontaneous bacterial peritonitis. Bacteriologically proven SIBO in proximal jejunal aspiration has been reported to be present in up to 59% of cirrhotic patients and is associated with systemic endotoxemia. Clinical and experimental studies suggest that delayed small bowel transit in liver cirrhosis may lead to SIBO, which could contribute to the symptoms of abdominal pain and diarrhea. In addition to autonomic neuropathy, metabolic derangements and diabetic state, SIBO itself may delay intestinal transit in cirrhotic patients. Several studies, both from the West and the East, have shown that the gut microbiota is altered in cirrhotic patients and particularly those with HE. Further, a quantitative change in Bacteroides/Firmicutes ratio, with a prevalence of potentially pathogenic bacteria (e.g., Enterobacteriaceae) and reduction in specific commensals (e.g., Lachnospiraceae), has been described. Structural and functional changes in the intestinal mucosa that contribute to increases in intestinal permeability for bacteria and their products have been observed in patients with liver cirrhosis, which is considered as an important pathogenetic factor for several complications. The mechanism of intestinal barrier dysfunction in cirrhosis is multifactorial, including alcohol, portal hypertension (vascular congestion and dysregulation), endotoxemia, SIBO, local inflammation and, most likely, immunological factors and medications.

Key Messages

This review summarizes major achievements regarding intestinal dysfunction in cirrhosis for future gastroenterology research. The question of whether this intestinal barrier dysfunction is accompanied and/or at least partly caused by structural and functional changes in the epithelial tight junction proteins is as yet unsolved. Development of new strategies to modulate gut-liver interaction is urgently needed.

Eradication of esophageal varices by sclerotherapy combined with argon plasma coagulation: Effect of portal hemodynamics and longitudinal clinical course

BACKGROUND AND AIM

To demonstrate the effect of endoscopic injection sclerotherapy (EIS) with argon plasma coagulation (APC) as a primary/secondary prophylaxis for esophageal varies (EV) on portal hemodynamics and long-term outcomes in cirrhosis.

METHODS

This prospective study included 48 cirrhotic patients (64.5 ± 11.4 years; 26 bleeders, 22 non-bleeders). Post-treatment outcomes (EIS and APC; median observation period, 12.8 months for recurrence and 21.1 months for prognosis) were evaluated with respect to the findings of hepatic venous catheterization, Doppler ultrasound, and endoscopic ultrasonography (EUS).

RESULTS

All patients showed EV eradication after endoscopic treatment, and a decreased frequency of a patent left gastric vein (pre: 83.3%, post: 27.1%, P < 0.001). However, hepatic venous pressure gradient (HVPG, mmHg) remained unchanged after the treatment, pre: 16.1 ± 3.6, post: 15.6 ± 3.8 (P = 0.269). Cumulative variceal recurrence/rebleeding rates were 25.5%/5.6% and 62.4%/23.1% at 1 and 3 years, respectively. Post-treatment EUS finding, area of submucosal vessels in the cardia ≥12 mm2 was the only significant factor for variceal recurrence (hazard ratio 9.769, 95% confidence interval 3.046-31.337; P < 0.001). Cumulative recurrence rate was significantly higher in patients with area of submucosal vessels in the cardia ≥12 mm2 (58.3% at 1 year and 100% at 3 years) than in those without (11.4% at 1 year and 40.9% at 3 years, P < 0.001). Cumulative overall survival rates were 95.2% and 71.9% at 1 and 3 years, respectively, showing no significant relationship with HVPG.

CONCLUSION

EIS with APC for EV is unlikely to have a significant influence on portal pressure.

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

AIM

To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy (PHG) based on a systematic literature review.

METHODS

Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "portal" and "gastropathy"; or "portal" and "hypertensive"; or "congestive" and "gastropathy"; or "congestive" and "gastroenteropathy". The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG.

RESULTS

PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG. PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepatic-portosystemic-shunt and liver transplantation are highly successful ultimate therapies because they reduce the underlying portal hypertension.

CONCLUSION

PHG is important to recognize in patients with cirrhotic or non-cirrhotic portal hypertension because it can cause acute or chronic GI bleeding that often requires pharmacologic therapy.

Black Spot, a Novel Gastric Finding Potentially Induced by Proton Pump Inhibitors

Objective We have recently discovered new gastric lesions with black spots. There have been no reports about black spots and their clinicopathological features. We therefore report the clinicopathological features of black spots and assess their causes and mechanisms. Methods Sixty-four patients with black spots among 26,620 Japanese patients that underwent endoscopy between May 2012 and October 2014 were enrolled. Endoscopic findings of black spots were defined as black pigmentations in the gastric mucosa by conventional endoscopy. We investigated the clinicopathological characteristics, including gender, age, underlying diseases and medications, endoscopic and pathologic findings of patients with black spots. Results The prevalence of patients with black spots was 0.24%. Of sixty-four cases, 44 (68.8%) were taking proton pump inhibitors (PPIs). Eight (12.5%) were taking corticosteroids. There were 10 cases (15.6%) with decreased renal function. All black spots were identified only in the fundic gland region. Forty-one (64.1%) patients had multiple (more than ten) black spots. There were two different types: black spots on the flat mucosa and black spots on fundic gland polyps. Pathologically, parietal cell protrusions, fundic gland cysts and brownish pigmentation in fundic gland cysts were seen in 26 (76.5%), 23 (67.6%) and 6 (17.6%) patients, respectively. Conclusion We herein describe gastric black spots as a new gastric mucosal finding that arises only in the fundic gland region. The black spots are pathologically brownish pigmentations in fundic gland cysts. Adverse events of PPIs and parietal cell protrusion caused by PPI use are strongly considered to be one of the etiologies of black spots.

Duodenal polyposis secondary to portal hypertensive duodenopathy

Portal hypertensive duodenopathy (PHD) is a recognized, but uncommon finding of portal hypertension in cirrhotic patients. Lesions associated with PHD include erythema, erosions, ulcers, telangiectasia, exaggerated villous pattern and duodenal varices. However, duodenal polyposis as a manifestation of PHD is rare. We report a case of a 52-year-old man who underwent esophagogastroduodenoscopy and was found with multiple small duodenal polyps ranging in size from 1-8 mm. Biopsy of the representative polyps revealed polypoid fragments of duodenal mucosa with villiform hyperplasia lined by reactive duodenal/gastric foveolar epithelium and underlying lamina propria showed proliferating ectatic and congested capillaries. The features were diagnostic of polyps arising in the setting of PHD.