This patient has cirrhosis and this upper endoscopy demonstrates the classic snake skin appearance of portal hypertensive gastropathy, a condition associated with an elevation of the portal venous pressure gradient typically seen in cirrhosis. The mucosa has this beefy, engorged appearance. This fine reticular lacelike pattern bordering the edematous gastric projections may represent engorged lymph within the epithelium
The severity of this lesion and its associated outcome, chronic gastrointestinal bleeding, has been correlated with the degree of portal hypertension. While increased gastric blood flow has been documented in patients with portal hypertensive gastropathy, it is not clear if increased venous pressure or passive congestive from portal hypertension has a true etiologic role. Further supporting this association with portal hypertension is the presence of esophageal varices seen here.
Histologically, we see on low power examination villiform architecture with expansion of lamina propria by fibro muscular stroma and subepithelial capillary proliferation c/w reactive gastropathy. On high power exam, in addition there are several ectatic capillaries without hyalinization of the wall or micro-thrombi within the lumen. These findings are c/ w portal hypertensive gastropathy. If within the lumen of these dilated capillaries, the pathologist can identify hyalinization or thrombus formation then the diagnosis of GAVE or gastric antral vascular ectasia must be considered
This second example is from a patient whose portal hypertension relates to post liver transplant complications. While a similar pattern is seen, the intensity of the edema and congestions appears less marked.
In general, the mucosal bleeding associated with portal hypertensive gastropathy responds to measures that successfully reduce the portal venous pressure gradient. These include beta blocker therapy, TIPPS, and portosystemic shunting. Medical therapy with octreotide has also been used with success. H-2 blockers, proton pump inhibitors and sulcrafate do not alone appear to be effective therapy but have not been studied in clinical trials. While the gastric antral vascular ectasia or GAVE also appears in increased frequency in patients with cirrhosis, this condition unlike portal hypertensive gastropathy does not improve with TIPSS or other methods aimed at reducing portal pressures.
Peter B. Kelsey, M.D., Harvard Medical School, Massachusetts General Hospital
Mari Mino-Kenudson, M.D., Harvard Medical School, Massachusetts General Hospital