Portal Hypertensive Gastropathy- An Overview

Introduction

Portal hypertensive gastropathy (PHG) is a condition characterized by changes in the gastric mucosa resulting from increased blood pressure in the portal vein, the primary vessel responsible for delivering blood to the liver. It is characterized by an elevation in blood pressure within the portal vein. Cirrhosis, also known as hepatic fibrosis, is frequently identified as a primary causative factor for this condition. PHG has the potential to induce internal bleeding, hence causing alterations in several aspects of the gastrointestinal tract.

What Are the Signs and Symptoms?

The majority of those diagnosed with PHG do not exhibit immediate symptoms. Nevertheless, if PHG deteriorates, it has the potential to give rise to more advanced manifestations, which encompass:

• Gastrointestinal hemorrhage (an occurrence of bleeding within the gastrointestinal tract).

• A deficiency of healthy red blood cells characterizes anemia.

• Inadequate wound healing.

• Elevated vulnerability to adverse reactions resulting from the ingestion of toxic substances, including pharmaceuticals, dietary items, and alcoholic beverages.

• The primary impact of PHG is observed on the gastric mucosa, which refers to the inner lining of the stomach.

Alterations to the mucosal lining, characterized by the presence of red or black-brown pigmented areas or the manifestation of either flat or protruding lesions, can solely be recognized through the utilization of an endoscopic examination. This medical treatment entails the insertion of a slender, illuminated tube through the oral cavity, allowing for visual inspection of the internal structures within the gastrointestinal system.

What Are the Different Complications?

Some factors that can contribute to the complexity of a situation are some complications.

• Ascites- A medical condition characterized by fluid accumulation in the abdominal cavity. The accumulation of fluid within the peritoneal cavity occurs when there is leakage of fluid from dilated veins. This phenomenon gives rise to abdominal swelling, leading to potential disruptions in appetite and digestion. In instances of heightened severity, the condition has the potential to expand into the thoracic cavity, impeding normal respiratory function. Additionally, it serves as a predisposing factor for the development of peritonitis, an infection within the peritoneal cavity.

• Gastrointestinal Hemorrhage- Rupturing and bleeding in the gastrointestinal tract can be attributed to the enlargement of veins. In severe situations, the veins within the stomach lining may undergo swelling, a condition known as portal hypertensive gastropathy, which can result in bleeding. The occurrence of bleeding can result in the development of anemia.

• Hypersplenism- It is a medical condition characterized by an overactive spleen. The phenomenon of splenic swelling occurs due to diminished blood circulation inside the spleen, leading to an accumulation of excessive blood volume. Consequently, the spleen forms novel blood vessels to accommodate the augmented blood flow. The condition of splenomegaly can lead to excessive activity of the spleen, resulting in the excessive removal of blood cells from circulation. This phenomenon may result in diminished blood clotting capabilities, characterized by a decrease in platelet count, as well as weakened immune response, shown by a decrease in white blood cell count.

• Hypoxemia- A condition characterized by insufficient levels of oxygen in the blood. Portal hypertension can lead to the dilation of blood arteries in the lungs in certain individuals. This condition hampers the respiratory system's capacity to facilitate oxygen exchange between the lungs and the bloodstream. The outcome manifests as hypoxemia, characterized by reduced oxygen levels in the bloodstream. The condition referred to as hepatopulmonary syndrome is widely recognized in medical literature.

• Renal Failure- The occurrence of vasodilation in blood vessels due to portal hypertension can lead to constriction of other blood arteries throughout the body. The occurrence of this phenomenon within the kidneys has the potential to induce renal failure through the constriction of blood flow. The medical condition referred to as hepatorenal syndrome is a rather uncommon consequence.

• Mild Cognitive Impairment (MCI)- A clinical condition characterized by a noticeable decline in cognitive abilities greater than expected for an individual's age and education level. The human body exhibits adaptive responses to portal hypertension by developing alternative vascular pathways that circumvent hepatic circulation. However, when blood circumvents the liver, it fails to undergo the intended filtration process. The accumulation of toxins in the bloodstream can ultimately lead to a decline in cognitive abilities. Individuals may experience transient episodes of confusion or disorientation, referred to as hepatic encephalopathy.

What Are the Underlying Factors That Contribute to This Disease?

Various factors contribute to the occurrence of this phenomenon. The medical condition is known as cirrhosis of the liver. Typically, this is the last phase of chronic liver disease, primarily associated with viral hepatitis C, alcohol-induced hepatitis, and nonalcoholic fatty liver disease.

• Hepatic Granulomas- Granulomas are aggregates of inflammatory cells that are commonly observed in the context of diverse infectious and inflammatory pathologies, including schistosomiasis. Benign tumors have the potential to impede the functionality of the portal venous system, and they frequently precede the subsequent development of fibrosis or the formation of scar tissue.

• The Formation of Blood Clots- Thrombosis occurring inside the portal venous system can impede the normal circulation of blood into, within, or out of the liver. Various factors can contribute to this phenomenon, one of which is the presence of inherited genetic disorders.

What Are the Many Diagnostic Procedures Available?

• Blood Testing- The full metabolic panel can detect kidney and liver dysfunction. A thorough hematological study can reveal spleen hyperactivity after leukocyte or platelet removal. It can also detect hematological issues that may cause portal hypertension or blood loss-related internal hemorrhage.

• Imaging Modalities- It helps diagnose cirrhosis, ascites, organomegaly, and portal venous system vein dilation or formation. Doppler ultrasonography technology can visualize vein blood flow. The device can identify and examine obstructions and abnormal expansions or contractions.

• Endoscopy Medical Procedure- If a patient has gastrointestinal bleeding symptoms, their doctor must perform an endoscopy. An endoscope, a long tube with a camera at its end, is used to visually investigate the esophagus, stomach, and duodenum during upper endoscopy. The doctors will check for varices and hemorrhaging. Instruments introduced through the endoscope may usually stop bleeding.

What Are the Strategies for Treatment?

Portal hypertension reversibility depends on its cause. Portal hypertension can improve or resolve with pharmacological treatment for an infection or blood clot. However, cirrhosis scar tissue seldom reverts, resulting in chronic portal hypertension. Treatment focuses on portal hypertension issues. Healthcare professionals usually prioritize crises over long-term solutions. First-line treatments for gastrointestinal bleeding include:

• Endoscopy Healthcare- The providers use endoscopic treatment to treat acute bleeding. Endoscopic sclerotherapy and banding are used. Sclerotherapy involves injecting a solution into bleeding varices. Banding stops varices bleeding using little rubber bands.

• Treatment With Drugs-. To reduce bleeding, doctors may use medications and endoscopic therapy to relieve varices pressure. Beta-blockers lower portal pressure, whereas vasoconstrictors constrict blood arteries.

Initial treatments for complicated portal hypertension may include:

• Oxygen therapy for hepatopulmonary syndrome.

• Dialysis treatment for hepatorenal syndrome.

• Drugs for hepatic encephalopathy.

• Paracentesis removes excess abdominal fluid in ascites. The fluid is then tested for peritonitis.

If bleeding or other concerns persist, doctors may use second-line therapy.

The second-line therapy includes the two shunt techniques that can shift blood flow in the portal venous system and relieve pressure.

• Transjugular Intrahepatic Portosystemic Shunt(TIPS)- It uses X-ray imaging to place a liver stent. Interventional radiologists conduct this. A needle establishes a liver tunnel to connect the portal vein to a hepatic vein. This blood flow diversion reduces pressure. Tunnel patency is maintained via a stent. The above approach is highly effective; however, stent failure over time is rare, requiring a second surgery.

• Distal Splenorenal Shunt (DSRS)- While it is important to be healthy enough to undergo surgery and recover without complications, surgery may improve illness management over time. The splenic vein is disconnected from the liver and redirected to the left kidney vein, reducing liver and spleen blood flow and pressure. Patients with advanced liver disease may be candidates for liver transplantation.

Conclusion

Although PHG can be effectively treated and maintained, it is crucial to address and manage the root cause(s) to achieve optimal outcomes. Early treatment of liver illness and portal hypertension, which are the prevailing etiologies of portal hypertensive gastropathy (PHG), is imperative to mitigate the risk of further complications. The identification of portal hypertensive gastropathy (PHG) in the context of esophageal varices has been determined to indicate subsequent esophageal variceal hemorrhage. If left untreated, portal hypertension has the potential to give rise to additional complications and may ultimately result in death.