**7. Conclusion**

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

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 effec-

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

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

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

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

antibiotic and resuscitation should be initiated and tailored to the patient's needs.

site and increasing the concentration of clotting factors [75].

PHG and number of transfusion requirements [76].

dose of 160 mg/day [68].

48 Stomach Disorders

tive as vasopressin [72].

**6.2. Endoscopic management**

**6.3. Surgical intervention**

In summary, GAVE and PHG are two clinically distinct entities that present with gastrointestinal blood loss. Majority of patients with portal hypertension and cirrhosis will develop PHG; however, it can also occur in the setting of noncirrhotic portal hypertension. GAVE is associated with gastric dysmotility, autoimmune reactivity, reduced gastrin levels, and elevated prostaglandins. It is not associated with cirrhosis. Therapy of PHG is directed toward lowering and stabilizing portal pressure with beta blockers or shunt procedures. GAVE management mainly involves the use of endoscopic methods to ablate bleeding lesions. When GAVE is complicated by cirrhosis, it is incumbent on clinicians to differentiate it from PHG as GAVE does not respond to treatments aimed at reduction of portal pressure.
