Opinion statement
Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are two distinct gastric mucosal lesions that may cause acute and/or chronic upper gastrointestinal hemorrhage in patients with cirrhosis. Whereas PHG is associated with portal hypertension, GAVE may present in patients without portal hypertension or liver disease. Diagnosis is made upon visualization of the characteristic lesions with upper gastrointestinal endoscopy, although the differential may be difficult at times. PHG is characterized endoscopically by a mosaic pattern with or without red signs and a proximal distribution. PHG mainly causes chronic blood loss and anemia in patients with cirrhosis but also can cause acute hemorrhage. First-line therapy for chronic hemorrhage from PHG is a nonselective β-blocker (propranolol or nadolol) and iron supplementation. If bleeding/anemia are not controlled with these measures and the patient is transfusion-dependent, shunt therapy (transjugular intrahepatic portosystemic shunt [TIPS] or shunt surgery) should be considered. Management of acute bleeding from PHG, an infrequent event, should be accomplished with a vasoactive drug, somatostatin (or its analogues) or terlipressin. If bleeding responds, the patient must be switched to a nonselective β-blocker. Shunt therapy should be considered in patients who rebleed or continue to bleed despite adequate β-blocker therapy. GAVE is less common than PHG. It is characterized by red spots without a background mosaic pattern, typically in the gastric antrum. When lesions have a linear distribution, the lesion is called “watermelon stomach.” GAVE is a cause of chronic gastrointestinal bleeding and anemia in patients with cirrhosis. If lesions are localized, first-line therapy is argon plasma coagulation. In more diffuse lesions, therapy with argon plasma coagulation is more complicated. Preliminary data suggest that cryotherapy may be a reasonable option for diffuse GAVE lesions. Neither β-blockers nor TIPS reduces the bleeding risk in patients with GAVE and thus should not be used in this setting.
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References and Recommended Reading
Primignani M, Carpinelli L, Preatoni P, et al.: Natural history of portal hypertensive gastropathy in patients with liver cirrhosis. The New Italian Endoscopic Club for the study and treatment of esophageal varices (NIEC). Gastroenterology 2000, 119:181–187.
Hashizume M, Sugimachi K: Classification of gastric lesions associated with portal hypertension. J Gastroenterol Hepatol 1995, 10:339–343.
McCormack TT, Sims J, Eyre-Brook I, et al.: Gastric lesions in portal hypertension: inflammatory gastritis or congestive gastropathy? Gut 1985, 26:1226–1232.
Spina GP, Arcidiacono R, Bosch J, et al.: Gastric endoscopic features in portal hypertension: final report of a consensus conference, Milan, Italy, September 19, 1992. J Hepatol 1994, 21:461–467.
Tanoue K, Hashizume M, Wada H, et al.: Effects of endoscopic injection sclerotherapy on portal hypertensive gastropathy: a prospective study. Gastrointest Endosc 1992, 38:582–585.
D’Amico G, Montalbano L, Traina M, et al.: Natural history of congestive gastropathy in cirrhosis. The Liver Study Group of V. Cervello Hospital. Gastroenterology 1990, 99:1558–1564.
Sarin SK, Shahi HM, Jain M, et al.: The natural history of portal hypertensive gastropathy: influence of variceal eradication. Am J Gastroenterol 2000, 95:2888–2893.
Ito K, Shiraki K, Sakai T, et al.: Portal hypertensive colopathy in patients with liver cirrhosis. World J Gastroenterol 2005, 11:3127–3130.
Menchen L, Ripoll C, Marin-Jimenez I, et al.: Prevalence of portal hypertensive duodenopathy in cirrhosis: clinical and haemodynamic features. Eur J Gastroenterol Hepatol 2006, 18:649–653.
Misra SP, Dwivedi M, Misra V: Prevalence and factors influencing hemorrhoids, anorectal varices, and colopathy in patients with portal hypertension. Endoscopy 1996, 28:340–345.
Bresci G, Parisi G, Capria A: Clinical relevance of colonic lesions in cirrhotic patients with portal hypertension. Endoscopy 2006, 38:830–835.
Merli M, Nicolini G, Angeloni S, et al.: The natural history of portal hypertensive gastropathy in patients with liver cirrhosis and mild portal hypertension. Am J Gastroenterol 2004, 99:1959–1965.
Fontana RJ, Sanyal AJ, Mehta S, et al.: Portal hypertensive gastropathy in chronic hepatitis C patients with bridging fibrosis and compensated cirrhosis: results from the HALT-C trial. Am J Gastroenterol 2006, 101:983–992.
Sarin SK, Sreenivas DV, Lahoti D, Saraya A: Factors influencing development of portal hypertensive gastropathy in patients with portal hypertension. Gastroenterology 1992, 102:994–999.
Gupta R, Saraswat VA, Kumar M, et al.: Frequency and factors influencing portal hypertensive gastropathy and duodenopathy in cirrhotic portal hypertension. J Gastroenterol Hepatol 1996, 11:728–733.
de la Pena J, Rivero M, Sanchez E, et al.: Variceal ligation compared with endoscopic sclerotherapy for variceal hemorrhage: prospective randomized trial. Gastrointest Endosc 1999, 49:417–423.
Sarin SK, Govil A, Jain AK, et al.: Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: influence on gastropathy, gastric varices and variceal recurrence. J Hepatol 1997, 26:826–832.
Hou MC, Lin HC, Chen CH, et al.: Changes in portal hypertensive gastropathy after endoscopic variceal sclerotherapy or ligation: an endoscopic observation. Gastrointest Endosc 1995, 42:139–144.
Conn HO, Grace ND, Bosch J, et al.: Propranolol in the prevention of the first hemorrhage from esophagogastric varices: a multicenter, randomized clinical trial. The Boston-New Haven-Barcelona Portal Hypertension Study Group. Hepatology 1991, 13:902–912.
Hosking SW, Kennedy HJ, Seddon I, Triger DR: The role of propranolol in congestive gastropathy of portal hypertension. Hepatology 1987, 7:437–441.
Perez-Ayuso RM, Pique JM, Bosch J, et al.: Propranolol in prevention of recurrent bleeding from severe portal hypertensive gastropathy in cirrhosis. Lancet 1991, 337:1431–1434.
Lo GH, Lai KH, Cheng JS, et al.: The effects of endoscopic variceal ligation and propranolol on portal hypertensive gastropathy: a prospective, controlled trial. Gastrointest Endosc 2001, 53:579–584.
Zhou Y, Qiao L, Wu J, et al.: Comparison of the efficacy of octreotide, vasopressin, and omeprazole in the control of acute bleeding in patients with portal hypertensive gastropathy: a controlled study. J Gastroenterol Hepatol 2002, 17:973–979.
Kouroumalis EA, Koutroubakis IE, Manousos ON: Somatostatin for acute severe bleeding from portal hypertensive gastropathy. Eur J Gastroenterol Hepatol 1998, 10:509–512.
Bruha R, Marecek Z, Spicak J, et al.: Double-blind randomized, comparative multicenter study of the effect of terlipressin in the treatment of acute esophageal variceal and/or hypertensive gastropathy bleeding. Hepatogastroenterology 2002, 49:1161–1166.
Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W: Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol 2007, 102:2086–2102.
Wagatsuma Y, Naritaka Y, Shimakawa T, et al.: Clinical usefulness of the angiotensin II receptor antagonist losartan in patients with portal hypertensive gastropathy. Hepatogastroenterology 2006, 53:171–174.
Karajeh MA, Hurlstone DP, Stephenson TJ, et al.: Refractory bleeding from portal hypertensive gastropathy: a further novel role for thalidomide therapy? Eur J Gastroenterol Hepatol 2006, 18:545–548.
Cremers MI, Oliveira AP, Alves AL, Freitas J: Portal hypertensive gastropathy: treatment with corticosteroids. Endoscopy 2002, 34:177.
Orloff MJ, Orloff MS, Orloff SL, Haynes KS: Treatment of bleeding from portal hypertensive gastropathy by portacaval shunt. Hepatology 1995, 21:1011–1017.
Urata J, Yamashita Y, Tsuchigame T, et al.: The effects of transjugular intrahepatic portosystemic shunt on portal hypertensive gastropathy. J Gastroenterol Hepatol 1998, 13:1061–1067.
Soin AS, Acharya SK, Mathur M, et al.: Portal hypertensive gastropathy in noncirrhotic patients. The effect of lienorenal shunts. J Clin Gastroenterol 1998, 26:64–67. Discussion 68.
Mezawa S, Homma H, Ohta H, et al.: Effect of transjugular intrahepatic portosystemic shunt formation on portal hypertensive gastropathy and gastric circulation. Am J Gastroenterol 2001, 96:1155–1159.
Kamath PS, Lacerda M, Ahlquist DA, et al.: Gastric mucosal responses to intrahepatic portosystemic shunting in patients with cirrhosis. Gastroenterology 2000, 118:905–911.
Vincent C, Pomier-Layrargues G, Dagenais M, et al.: Cure of gastric antral vascular ectasia by liver transplantation despite persistent portal hypertension: a clue for pathogenesis. Liver Transpl 2002, 8:717–720.
Spahr L, Villeneuve JP, Dufresne MP, et al.: Gastric antral vascular ectasia in cirrhotic patients: absence of relation with portal hypertension. Gut 1999, 44:739–742.
Suit PF, Petras RE, Bauer TW, Petrini JL, Jr: Gastric antral vascular ectasia. A histologic and morphometric study of “the watermelon stomach.” Am J Surg Pathol 1987, 11:750–757.
Dulai GS, Jensen DM, Kovacs TO, et al.: Endoscopic treatment outcomes in watermelon stomach patients with and without portal hypertension. Endoscopy 2004, 36:68–72.
Sato T, Yamazaki K, Toyota J, et al.: Efficacy of argon plasma coagulation for gastric antral vascular ectasia associated with chronic liver disease. Hepatol Res 2005, 32:121–126.
Yusoff I, Brennan F, Ormonde D, Laurence B: Argon plasma coagulation for treatment of watermelon stomach. Endoscopy 2002, 34:407–410.
Sebastian S, McLoughlin R, Qasim A, et al.: Endoscopic argon plasma coagulation for the treatment of gastric antral vascular ectasia (watermelon stomach): long-term results. Dig Liver Dis 2004, 36:212–217.
Roman S, Saurin JC, Dumortier J, et al.: Tolerance and efficacy of argon plasma coagulation for controlling bleeding in patients with typical and atypical manifestations of watermelon stomach. Endoscopy 2003, 35:1024–1028.
Kwan V, Bourke MJ, Williams SJ, et al.: Argon plasma coagulation in the management of symptomatic gastrointestinal vascular lesions: experience in 100 consecutive patients with long-term follow-up. Am J Gastroenterol 2006, 101:58–63.
Labenz J, Borsch G: Bleeding watermelon stomach treated by Nd-YAG laser photocoagulation. Endoscopy 1993, 25:240–242.
Mathou NG, Lovat LB, Thorpe SM, Bown SG. Nd:YAG laser induces long-term remission in transfusion-dependent patients with watermelon stomach. Lasers Med Sci 2004, 18:213–218.
Selinger RR, McDonald GB, Hockenbery DM, et al.: Efficacy of neodymium:YAG laser therapy for gastric antral vascular ectasia (GAVE) following hematopoietic cell transplant. Bone Marrow Transplant 2006, 37:191–197.
Kantsevoy SV, Cruz-Correa MR, Vaughn CA, et al.: Endoscopic cryotherapy for the treatment of bleeding mucosal vascular lesions of the GI tract: a pilot study. Gastrointest Endosc 2003, 57:403–406.
Cho S, Yong E, Zanati S, et al.: Endoscopic cryotherapy for the management of gastric antral vascular ectasia (GAVE): a pilot study [abstract]. Gastrointest Endosc 2006, 63:AB81.
Tran A, Villeneuve JP, Bilodeau M, et al.: Treatment of chronic bleeding from gastric antral vascular ectasia (GAVE) with estrogen-progesterone in cirrhotic patients: an open pilot study. Am J Gastroenterol 1999, 94:2909–2911.
McCormick PA, Ooi H, Crosbie O: Tranexamic acid for severe bleeding gastric antral vascular ectasia in cirrhosis. Gut 1998, 42:750–752.
Park RH, Danesh BJ, Upadhyay R, et al.: Gastric antral vascular ectasia (watermelon stomach)—therapeutic options. Postgrad Med J 1990, 66:720–723.
Dunne KA, Hill J, Dillon JF: Treatment of chronic transfusion-dependent gastric antral vascular ectasia (watermelon stomach) with thalidomide. Eur J Gastroenterol Hepatol 2006, 18:455–456.
Caletti GC, Brocchi E, Ferrari A, et al.: Value of endoscopic ultrasonography in the management of portal hypertension. Endoscopy 1992, 24(Suppl 1):342–346.
Nardone G, Rocco A, Balzano T, Budillon G: The efficacy of octreotide therapy in chronic bleeding due to vascular abnormalities of the gastrointestinal tract. Aliment Pharmacol Ther 1999, 13:1429–1436.
Mann NS, Rachut E: Gastric antral vascular ectasia causing severe hypoalbuminemia and anemia cured by antrectomy. J Clin Gastroenterol 2002, 34:284–286.
Pljesa S, Golubovic G, Tomasevic R, et al.: “Watermelon stomach” in patients on chronic hemodialysis. Ren Fail 2005, 27:643–646.
Jabbari M, Cherry R, Lough JO, et al.: Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology 1984, 87:1165–1170.
Ward EM, Raimondo M, Rosser BG, et al.: Prevalence and natural history of gastric antral vascular ectasia in patients undergoing orthotopic liver transplantation. J Clin Gastroenterol 2004, 38:898–900.
Cirera I, Feu F, Luca A, et al.: Effects of bolus injections and continuous infusions of somatostatin and placebo in patients with cirrhosis: a double-blind hemodynamic investigation. Hepatology 1995, 22:106–111.
Escorsell A, Bandi JC, Andreu V, et al.: Desensitization to the effects of intravenous octreotide in cirrhotic patients with portal hypertension. Gastroenterology 2001, 120:161–169.
Baik SK, Jeong PH, Ji SW, et al.: Acute hemodynamic effects of octreotide and terlipressin in patients with cirrhosis: a randomized comparison. Am J Gastroenterol 2005, 100:631–635.
Spahr L, Giostra E, Frossard JL, et al.: A 3-month course of long-acting repeatable octreotide (sandostatin LAR) improves portal hypertension in patients with cirrhosis: a randomized controlled study. Am J Gastroenterol 2007, 102:1397–1405.
Villanueva C, Planella M, Aracil C, et al.: Hemodynamic effects of terlipressin and high somatostatin dose during acute variceal bleeding in nonresponders to the usual somatostatin dose. Am J Gastroenterol 2005, 100:624–630.
Escorsell A, Bandi JC, Moitinho E, et al.: Time profile of the haemodynamic effects of terlipressin in portal hypertension. J Hepatol 1997, 26:621–627.
Bolognesi M, Balducci G, Garcia-Tsao G, et al.: Complications in the medical treatment of portal hypertension. In Portal Hypertension III. Oxford: Blackwell Science; 2001:180–203.
Angermayr B, Cejna M, Koenig F, et al.: Survival in patients undergoing transjugular intrahepatic portosystemic shunt: ePTFE-covered stentgrafts versus bare stents. Hepatology 2003, 38:1043–1050.
Boyer TD, Haskal ZJ: American Association for the Study of Liver Diseases Practice Guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the management of portal hypertension. J Vasc Interv Radiol 2005, 16:615–629.
Banares R, Nunez O, Escudero M, et al.: Patients with cirrhosis and bare-stent TIPS may have increased risk of hepatocellular carcinoma. Hepatology 2005, 41:566–571.
Bureau C, Garcia-Pagan JC, Otal P, et al.: Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology 2004, 126:469–475.
Wahab PJ, Mulder CJ, den Hartog G, Thies JE: Argon plasma coagulation in flexible gastrointestinal endoscopy: pilot experiences. Endoscopy 1997, 29:176–181.
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Ripoll, C., Garcia-Tsao, G. Treatment of gastropathy and gastric antral vascular ectasia in patients with portal hypertension. Curr Treat Options Gastro 10, 483–494 (2007). https://doi.org/10.1007/s11938-007-0048-5
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DOI: https://doi.org/10.1007/s11938-007-0048-5