**6. Management of PHG**

#### **6.1. Medical treatment**

The management of PHG is focused on abating portal pressure, mainly through the use of medical therapy rather than endoscopic means. Similar to esophageal varices, management attempts to reduce hepatic venous pressure gradient (HVPG) to <12 mmHg or by 20% which correlates with a reduction in mortality in some studies [65]. A meta-analysis established that target HVPG is a valid marker to monitor drug efficacy for variceal bleeding and patient prognosis [65]. Beta blockers are first-line drugs used to reduce portal pressure and have the most benefit in patients with mild PHG [66]. Modest effects have been noted in patients with severe PHG [67]. It is unclear whether beta blockers are prophylactically effective in preventing bleeding from PHG [24]. However, in patients receiving propranolol or nadolol for esophageal variceal bleeding prophylaxis, beta blocker therapy showed a reduction in future PHG bleeding [68].

In a randomized controlled trial to investigate the efficacy of propranolol, 26 of 54 patients received propranolol and the rest placebo. Daily doses of 40–320 mg were used. In the cohort receiving propranolol, patients reported significantly lower rates of rebleeding (38 vs. 65%) at 12 months and at 30 months (7 vs. 52%) compared with controls [67]. Similarly, a smaller study using a dose of 24–480 mg/day decreased the incidence of acute bleeding in 16 patients with PHG and also reduced the grade of PHG in 24 asymptomatic patients when given at a dose of 160 mg/day [68].

In unstable patients who have contraindications for beta blockers, other agents have been studied with varying efficacy including somatostatin, octreotide, terlipressin, and vasopressin [69–72]. Somatostatin and its analogs showed complete control of acute bleeding with 11% rebleeding after withdrawing infusion [69]. Octreotide controlled bleeding in 100% of patients within 48 h. Vasopressin controlled bleeding in 64% of patients over the same time [71]. Terlipressin, a vasopressin analog (not available in the United States), was similarly effective as vasopressin [72].

#### **6.2. Endoscopic management**

Acute bleeding in the setting of PHG rarely occurs. A large study reported an incidence of acute bleeding from gastropathy in 8 of 315 patients (2.5%), compared to chronic bleeding which occurred in 34 patients (10.8%) [73]; however, if it occurs, such bleeding episodes can be severe and challenging to manage. In addition to intravenous medical therapy with aforementioned agents aimed at reducing portal pressure and hemostatic control, appropriate antibiotic and resuscitation should be initiated and tailored to the patient's needs.

Endoscopic therapy for acute bleeding from PHG remains investigational and may provide temporary control. For patients with refractory bleeding who are not candidates for portosystemic shunting, limited data suggest that endoscopic thermal therapy may be efficacious. Similar to GAVE, APC has proven successful in controlling bleeding and reducing transfusion requirements [74]. Furthermore, hemostatic powder is emerging as a useful means for managing patients with acute bleeding. The powder acts by forming a barrier over the bleeding site and increasing the concentration of clotting factors [75].

#### **6.3. Surgical intervention**

In cases of failed medical or endoscopic therapy requiring increase blood transfusions, portosystemic shunt therapy should be considered through the placement of a transjugular intrahepatic portosystemic shunt (TIPS). Shunting works by relieving portal hypertension with the placement of a tube (shunt) between the portal vein which carries blood from the intestines to the liver and the hepatic vein which carries blood from the liver back to the heart. Patients who have the TIPS procedure show significant improvement in endoscopic appearance of PHG and number of transfusion requirements [76].

A prospective study of 30 patients with mild PHG and 10 patients with severe PHG with recurrent GI bleeding had a 75% reduction in endoscopic severity, a Childs-Pugh Score of 11.5, and a mean reduction in portacaval gradient from 20 to 12 mmHg following TIPS [17]. Patients typically show endoscopic improvement in 6 weeks for mild cases and up to 3 months for more severe cases of PHG [77]. A retrospective study of 40 Child-Pugh class A and B cirrhotic patients comparing surgical shunting and TIPS found improved outcomes from surgical shunting with reduced 30-day mortality, reduced rebleeding events, and fewer shunt revisions and hospitalizations [78].

However, surgical shunting carries risks of substantial perioperative morbidity and mortality. In those who survive operation, accelerated hepatic decompensation and neuropsychologic deterioration (portosystemic encephalopathy) significantly diminish the overall benefit of the shunting procedure [78]. Similarly, TIPS carries a potential risk for rapid liver failure necessitating liver transplantation [79].
