UNLOCKING THE MYSTERIES OF PORTAL HYPERTENSIVE GASTROPATHY Increased Gastric Mucosal Perfusion in Cirrhotic Patients with Portal Hypertensive Gastropathy

Panes and co‐investigators designed an elaborate study in which endoscopic probe reflectance spectrophotometry (1, 2) and laser doppler flowmetry (3–5) were used to study gastric mucosal perfusion in 34 cirrhotic patients with portal hypertensive gastropathy (PHG) and 24 noneirrhotic patients. PHG was defined as mild (mosaic or scarlatina mucosal pattern) or severe (red spots on a granular mucosa). Mild PHG was observed in 14 of the cirrhotics, and severe PHG in 20. The distribution of lesions was also recorded, as was the presence of esophageal varices. The severe PHG patients had significantly lower hemoglobins (9.8 ± 0.4 g/dl) than those in the mild PHG group (11.7 ± 0.4 g/dl). Portal pressure determinations (wedged minus free hepatic venous pressure) and azygos vein flow also were obtained in the PIIG patients (seven mild PHG; 10 severe PHG). Mucosal perfusion, estimated by mucosal hemoglobin (1Hb), was higher in the cirrhotics with PHG but distributed more widely in the body than in the antrum, as similarly observed in the controls. Although there was no difference in mucosal perfusion between the greater and lesser curvatures in the PHG group, there was an increased perfusion in the greater curvature of the controls. Mucosal oxygen content (ISO₂) measurements were not different in the two groups of patients. To compare the gastric perfusion between the PHG group and the controls more accurately, we calculated an index of the hemoglobin content of the gastric mucosa, and the IIIb ratio (spectrophotometrically measured IIIb divided by blood hemoglobin), correcting for the significant proportion of anemic cirrhotics with severe PHG. Reflectance spectrophotometry revealed a significantly higher IIIb ratio in the PHG patients than in the noncirrhotic controls. Gastric mucosal blood flow by laser Doppler flowmetry was also significantly higher In the PHG group. Comparing gastric perfusion in the different regions of the stomach, we found that the PHG group had higher overall IIIb ratios and laser Doppler signals in all areas. Of interest, gastric perfusion in cirrhotics with PHG was not significantly correlated with Child‐Pugh classification. The investigators examined the relationship between their measured estimates of gastric perfusion and the severity of PHG The 1Hb ratio paralleled the severity of PHG, with values significantly higher in both the body and antrum. Laser doppler flow values were also higher in both locations in patients with severe PHG, reaching significance in the antrum. There was no significant difference in ISO₂ (mucosal oxygen content) between mild and severe lesions. The results from splanchnic hemodynamic measurements in 17 patients with mild and severe PHG revealed no correlation between the IIIb ratio and laser doppler signal (mucosal perfusion) and the wedged hepatic venous pressure, the hepatic venous pressure gradient, or azygous blood flow, collectively, and when mild versus severe PHG were compared. The authors concluded that cirrhotic patients with PHG have increased gastric perfusion which correlates with the endoscopic severity of PHG. The magnitude of changes in gastric perfusion and endoscopic severity of PHG has no relationship to the degree of portal hypertension or azygous blood flow.