Underlying etiology of these disorders though to be secondary to portal hypertension, exact pathogenesis is unknown.

Portal Hypertensive Gastropathy (PHG)

Present in 20-98% of cirrhotic patients. More associated with more severe portal hypertension, and with esophageal varices, history of sclerotherapy or ligation for varices.

The major histologic changes in PHG include dilatation of capillaries and venules in the mucosa and submucosa without significant inflammation. Several studies have shown that abnormalities in the mucosal microcirculation may be related to the congestion seen in PHG.

Clinical Findings

Mostly asymptomatic; can present with evidence of chronic GIB and chronic Iron deficiency anemia.

Acute GIB is less common, between 2-12% prevalence in cirrhotics.

Diagnostic Modalities

Endoscopy evaluation is required: typical findings are a "snakeskin mosaic" pattern, flat or bulging red marks or red spots resembling vascular ectasia, or black-brown spots. Typically found in the proximal stomach (fundus and body)

Treatment

Primary Prophylaxis

Generally not recommended. Consider use of NSBB for those with esophageal varices as well, or if the PHG is severe.

Chronic Bleeding

Replete iron stores
Consider starting oral propanolol (up to 160 mg BID) with a goal HR of 50-55 BPM.

Acute Bleeding

Standard supportive care
SBP prophylaxis with Child-Pugh B or C cirrhosis
Initiate vasoconstrictor therapies (octreotide)
Advance to endoscopy when possible
Endoscopic treatment of acute bleeding secondary to PHG is generally not effective. APC can be considered for individual lesions.

Secondary Prevention

NSBB are indicated.

Portal Hypertensive Colopathy

Colorectal mucosa suffers from similar changes seen in PHG. On endoscopy, there are vascular ectasia and rectal varices seen.

Bleeding from PHC is less common than with PHG. PHC is generally asymptomatic but can cause insidious chronic LGIB and iron deficiency.

Diagnosed via endoscopy.

Treatment of PHC

There is no standard treatment of PHC. Small case series argue for use of similar vasoactive medications (octreotide, somatostatin, NSBB).

Replete iron, consider NSBB initiation.

Consider endoscopic therapies.

TIPS for salvage therapy.

References

Urrunaga NH, Rockey DC. Portal Hypertensive Gastropathy and Colopathy. Clin Liver Dis. 2014;18(2):389-406. doi:10.1016/j.cld.2014.01.008