Treatment of bleeding from portal hypertensive gastropathy by portacaval shunt

Abstract

Portal hypertensive gastropathy is a vascular disorder of the gastric mucosa distinguished by ectasia of the mucosal capillaries and submucosal veins without inflammation. During 1988 to 1993, 12 patients with biopsy-proven cirrhosis (10 alcoholic, 2 posthepatitic) were evaluated and treated prospectively by portacaval shunt for active bleeding from severe portal hypertensive gastropathy. Eleven patients had been hospitalized for bleeding three to nine times previously, and one was bleeding uncontrollably for the first time. Requirement for blood transfusions ranged from 11 to 39 units cumulatively, of which 8 to 30 units were required specifically to replace blood lost from portal hypertensive gastropathy. Admission findings were ascites in 9 patients, jaundice in 8, severe muscle wasting in 10, hyperdynamic state in 9. Child's risk class was C in 7, B in 4, A in 1. Ten of the 12 patients had previously received repetitive endoscopic sclerotherapy for esophageal varices, which has been reported to precipitate portal hypertensive gastropathy. Eight patients had failed propranolol therapy for bleeding. Portacaval shunt was performed emergently in 11 patients and electively in 1, and permanently stopped bleeding in all by reducing the mean portal vein-inferior vena cava pressure gradient from 251 to 16 mm saline. There were no operative deaths, and two unrelated late deaths after 13 and 24 months. During 1 to 6.75 years of follow-up, all shunts remained patent by ultrasonography, the gastric mucosa reverted to normal on serial endoscopy, and there was no gastrointestinal bleeding. Recurrent portal-systemic encephalopathy developed in only 8% of patients. Quality of life was generally good.(ABSTRACT TRUNCATED AT 250 WORDS)

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

“…In contrast, GAVE does not resolve after lowering portal pressure with TIPS, and GAVE is, therefore, likely related to hepatic dysfunction rather than portal hypertension [78] . TIPS also decreased the risk of PHG bleeding [75][76][77]100,[249][250][251][252][253] . For example, Kamath et al [75] reported TIPS led to improvement or resolution of PHG findings and decreased transfusion requirements from 2.9 ± 2.0 (SD) units/mo of packed erythrocytes before TIPS to 0.6 ± 0.8 units/mo after TIPS performed for severe PHG (P = 0.04).…”

“…Table 5 [8, 9,11,14,34,41,55,62,67,71,83,85] lists wellestablished risk factors for PHG; Table 6 [11,41, 44,55,[75][76][77]83,85,[98][99][100][101][102][103][104][105][106][107] lists therapies that affect the severity of PHG or the risk of bleeding from PHG, and Table 7 [8, 14,28,30,35,42,84,[108][109][110] lists the factors that do not affect the risk of PGH.…”

“…Shunt surgery: Shunt surgery decreases portal hypertension, decreases PHG severity, decreases risk of PHG bleeding, and may sometimes completely resolve the endoscopic features of PHG [100] . Shunt surgery is rarely used today to control bleeding because TIPS is preferred because of less invasiveness [100,101,238,254] .…”

“…Shunt surgery is rarely used today to control bleeding because TIPS is preferred because of less invasiveness [100,101,238,254] . TIPS and shunt surgery are therapies of last resort for patients who fail other therapies for PHG because they entail more morbidity and mortality than pharmacologic therapy [71] .…”

Portal-Systemic Encephalopathy in Emergency Treatment of Cirrhosis and Bleeding Esophageal Varices

“…The question is, can cirrhotic patients tolerate an operation of this magnitude when it is performed as an emergency in the face of bleeding? To answer this question, we have conducted prospective studies of emergency PCS (EPCS) over the past 47 years, as follows: (1) an unrandomized study of 400 unselected patients who underwent EPCS; (2) a RCT of EPCS versus emergency medical therapy involving 43 patients at our Veterans Administration Hospital; (3) an unrandomized study of 94 unselected, consecutive patients with Child's class C cirrhosis; (4) a RCT of portacaval shunt versus endoscopic sclerotherapy in 518 unselected patients bleeding from gastric varices; (5) a n u n r a n d o m i z e d s t u d y i n 1 2 p a t i e n t s w i t h u n c o n t r o l l a b l e b l e e d i n g f r o m p o r t a l hypertensive gastropathy; (6) a NIH grant supported RCT of EPCS versus emergency endoscopic sclerotherapy (EST) that enrolled 211 patients who have had more than 10 years of follow-up or until death; and (7) a NIH grant supported RCT of TIPS versus EPCS that enrolled 154 patients who have been followed up for 5-10 years (Orloff, 1967;Orloff et al, 1980;Orloff et al, 1992;Orloff et al, 1994;Orloff et al, 1995a;Orloff et al, 2009a;Orloff et al, 2009b;Orloff et al, 2011a;Orloff et al, 2011b;Orloff et al, 2010;Orloff et al, 2011c;Orloff et al, 2011d;Orloff et al, 2011e;Orloff et al, 2011f;Orloff et al, 2011g;Orloff et al, 2011h;Orloff et al, 2011i;Orloff & Bell, 1983;Bell, et al, 1981;Orloff, 1968;Orloff, 1969;Orloff et al, 1974;Orloff et al, 1975;Orloff & Bell, 1986;Orloff et al, 1995b;Orloff et al, 1997) . The unique features of our studies that, together, make them different from other reported investigations are as follows: (1) EPCS was undertaken within 24 h of initial contact of the patient with our institution in one study and within 8 h in the other six studies; (2) the patients were unselected, which means that all patients with bleeding varices, regardless of their condition ("all comers"), were entered in the studies and treated; (3) the studies were prospective, which means that the p...…”