Portal hypertensive gastropathy (PHG) is an endoscopic finding produced by widening of the vessels in the stomach lining and a change in blood flow, caused by raised pressure in the portal venous system.
It is seen most often in patients with cirrhosis and portal hypertension.
Portal hypertensive gastropathy is not cancer. But in some patients it can cause gastrointestinal bleeding and anaemia.
How does it look at endoscopy?
Portal hypertensive gastropathy has quite a characteristic appearance. The stomach lining may show:
- A mosaic or net-like appearance
- A surface described as “snakeskin”
- Red spots or patches
- In more severe cases, widespread red areas and bleeding
It is generally more marked in the corpus and fundus of the stomach.
What causes it?
The underlying problem lies less in the stomach itself than in portal hypertension.
Normally, blood from the intestines reaches the liver through the portal vein. When resistance to blood flow within the liver increases, pressure rises in the portal system.
The most common cause: cirrhosis of the liver → portal hypertension → changes in the circulation of the stomach’s vessels → portal hypertensive gastropathy.
But it can also be seen with causes of portal hypertension other than cirrhosis.
Is it the same as gastritis?
No. This is exactly why it is called a “gastropathy”.
Gastritis describes inflammation in the stomach lining. Portal hypertensive gastropathy relates to vascular and circulatory changes due to raised portal pressure.
For this reason the treatment of PHG differs from that of classic gastritis.
Is it the same as oesophageal or gastric varices?
No, but they can be present together in the same patient. Both can have portal hypertension underlying them.
- Varices Are the marked widening of particular veins.
- Portal hypertensive gastropathy Is more widespread vascular change throughout the stomach lining.
So both oesophageal varices and portal hypertensive gastropathy can be seen in the same patient at endoscopy.
Does it cause symptoms?
A substantial proportion of patients have no obvious symptoms. Its main clinical importance is the possibility of bleeding. Bleeding can appear in two ways:
- Slow, chronic bleeding: can lead over time to iron deficiency and anaemia.
- Acute bleeding: less common; can appear as black stools or vomiting blood.
Can it cause anaemia?
Yes.
If small amounts of blood are lost from the lining over a long period, a low haemoglobin + low iron + low ferritin can be seen.
So in a patient with portal hypertensive gastropathy who develops anaemia, the possibility of chronic gastrointestinal blood loss is assessed.
What do mild and severe portal hypertensive gastropathy mean?
The endoscopic appearance can be classified roughly as mild or severe.
- Mild PHG The typical mosaic / snakeskin appearance predominates.
- Severe PHG In addition to the mosaic appearance there may be marked red or dark brown-black patches and active bleeding.
The risk of bleeding matters more in the severe form.
How is it treated?
The main aim of treatment is to control not the stomach alone but the portal hypertension. Depending on the patient’s situation, options may include:
- Non-selective beta-blockers, which reduce portal pressure
- Iron treatment where there is iron deficiency
- Appropriate urgent treatment where there is acute bleeding
- Endoscopic treatments in selected, resistant bleeding
- TIPS in some cases that cannot be controlled
Acid-suppressing medicines such as PPIs are not the main treatment for PHG. They may be used where there is another indication, but they do not treat portal hypertension.
Is it the same as GAVE?
No. This distinction matters.
GAVE (gastric antral vascular ectasia) and portal hypertensive gastropathy can sometimes be confused at endoscopy.
PHG is seen mostly in the corpus and fundus and produces a mosaic/snakeskin appearance. GAVE is mostly in the antrum, in the form of red stripes running out from the pylorus, which is why it is also called “watermelon stomach”.
Their treatments differ too.
Does it cause cancer?
No.
Portal hypertensive gastropathy is not cancer and is not considered a pre-cancerous lesion. The main problem here is the risk of bleeding and the underlying portal hypertension.
When is urgent assessment needed?
If these develop, gastrointestinal bleeding should be considered and urgent assessment carried out
Vomiting blood · vomit that looks like coffee grounds · black, tarry stools · dizziness or fainting · palpitations · a drop in blood pressure · sudden and marked weakness.
Remember
- Portal hypertension Is the underlying cause of PHG.
- Endoscopy Typically shows a mosaic / snakeskin appearance.
- PHG Is not cancer.
- PHG Can cause chronic blood loss, iron deficiency and, rarely, acute bleeding.
- PHG Is not the same thing as gastritis, oesophageal or gastric varices, or GAVE (watermelon stomach).
- The main aim of treatment Is to reduce portal hypertension.
This is not enough to make a diagnosis
When portal hypertensive gastropathy is found at endoscopy, it is not the stomach finding alone that matters but the cause and severity of the liver disease, the degree of portal hypertension, any oesophageal or gastric varices, and the haemoglobin and iron values, all weighed together.
Sources
- Prof. Ali Tüzün İnce, MD