Efficacy of argon plasma coagulation in the management of portal hypertensive gastropathy

Objectives: Evaluation of the outcome and experience in 2 years of management of portal hypertensive gastropathy (PHG) by argon plasma coagulation (APC) in a cohort of Egyptian cirrhotic patients.

Methods: This study was conducted over a 2-year period from January 2011 to February 2013. Upper gastrointestinal endoscopy was performed to evaluate the degree and site of PHG. APC was applied to areas with mucosal vascular lesions.

Results: In total, 200 cirrhotic patients were enrolled; 12 patients were excluded due to death (n = 6) caused by hepatic encephalopathy (n = 3), hepatorenal syndrome (n = 2), or chronic lymphatic leukemia (n = 1), or did not complete the treatment sessions (n = 6), so 188 patients completed the study. PHG was mainly fundic in 73 patients (38.8 %), corporeal in 66 patients (35.1 %), and pangastric in 49 patients (26.1 %) (P = 0.026). Patients were exposed to APC and received proton pump inhibitors together with propranolol at a dose sufficient to reduce the heart rate by 25 % or down to 55 beats/min. The mean (± standard deviation) number of sessions was 1.65 ± 0.8; six patients needed four sessions (3.2 %), 19 patients needed three sessions (10.1 %), 74 patients needed two sessions (39.4 %), and 89 patients needed one session (47.3 %). Patients with fundic and corporeal PHG required the lowest number of sessions (P = 0.000). Patients were followed up every 2 months for up to 1 year; the end point was a complete response with improved anemia and blood transfusion requirement which was achieved after one session in 89 patients (75.4 %), two sessions in 24 patients (20.3 %) and three sessions in five patients (4.3 %). A complete response was more prevalent in patients with corporeal and fundic PHG (P = 0.04).

Conclusions: After 2 years’ experience in managing PHG, we found that a combination of APC and non-selective beta blockers was highly efficacious and safe in controlling bleeding from PHG. In addition, APC alone is rapid, and effective in the control of PHG induced bleeding, especially when beta blockers are contraindicated.

• References

• 1 Lubel JS, Angus PW. Modern management of portal hypertension. J Intern Med 2005; 35: 45-49
• 2 Stiegmann V. Diagnosis and management of ectopic varices. J Gastroenterol Hepatol 2004; 19: 168-173
• 3 Samonakis DM, Triantos CK, Thalheimer H et al. Management of portal hypertension. Postgrad Med J 2004; 80: 634-641
• 4 David C, Maic S, Ginsberg T et al. Portal hypertensive gastropathy: Radiographic finding in eight patients. Am J Roentgenol 2000; 175: 1609-1612
• 5 McCormick PA, Sankey EA, Cardin F et al. Congestive gastropathy and Helicobacter pylori: an endoscopic and morphometric study. Gut 1991; 32: 351-354
• 6 Zoli M, Merkel C, Magalotti D et al. Evaluation of a new endoscopic index to predict first bleeding from the upper gastrointestinal tract in patients with cirrhosis. Hepatology 1996; 24: 1047-1052
• 7 Primignani M, Carpinelli L, Preatoni P et al. Portal hypertensive gastropathy (PHG) in liver cirrhosis: natural history. A multicenter study by the New Italian Endoscopic Club (NIEC). J Gastroenterol 1996; 110: 1299
• 8 McCormack TT, Sims J, Eyre-Brook I et al. Gastric lesions in portal hypertension: Inflammatory gastritis or congestive gastropathy?. Gut 1985; 26: 1226-1232
• 9 Spina GP, Arcidiacono R, Bosch J et al. Gastric endoscopic features in portal hypertension: final report of a consensus conference, Milan, Italy, September 19, 1992. J Hepatol 1994; 21: 461-467
• 10 Sarin SK. Diagnostic issue: Portal hypertensive gastropathy and gastric varices. In: DeFranchis R, ed. Portal hypertension II. Proceedings of the second Baveno international consensus workshop on definitions, methodology and therapeutic strategies. Oxford: Blackwell Science; 1996: 30-55
• 11 Gostout CJ, Viggiano TR, Ahlquist DA et al. The clinical and endoscopic spectrum of the watermelon stomach. J Clin Gastroenterol 1992; 15: 256-263
• 12 Novitsky YW, Kercher KW, Czerniach DR et al. Watermelon stomach: pathophysiology, diagnosis, and management. J Gastrointest Surg 2003; 7: 652-661
• 13 Burak KW, Lee SS, Beck PL. Portal hypertensive gastropathy and gastric antral vascular ectasia (GAVE) syndrome. Gut 2001; 49: 866-872
• 14 D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol 2006; 44: 217-231
• 15 Panes J, Bordas JM, Pique JM et al. Effects of propranolol on gastric mucosal perfusion in cirrhotic patients with portal hypertensive gastropathy. Hepatology 1993; 17: 213-218
• 16 Kouroumalis EA, Koutroubakis IE, Manousos ON. Somatostatin for acute severe bleeding from portal hypertensive gastropathy. Eur J Gastroenterol Hepatol 1998; 10: 509-512
• 17 Zhou Y, Qiao L, Wu J et al. Comparison of the efficacy of octreotide, vasopressin, and omeprazole in the control of acute bleeding in patients with portal hypertensive gastropathy: a controlled study. J Gastroenterol Hepatol 2002; 17: 973-979
• 18 Bezawit D, Tekola MD, Stephen CM. Approach to the management of portal hypertensive gastropathy and gastric antral vascular ectasia. Clin Liver Dis 2012; 1: 163-166
• 19 Gonzalez-Suarez B, Monfort D, Piqueras M et al. Endoscopic treatment with Argon plasma coagulation for portal hypertensive gastropathy with no response to pharmacological therapy [abstract]. J Hepatol 2003; 38: 59
• 20 Mathurin SA, Aguero AP, Dascani NA et al. [Anaemia in hospitalized patients with cirrhosis: prevalence, clinical relevance and predictive factors] [article in Spanish]. Acta Gastroenterol Latinoam 2009; 39: 103-111
• 21 Sarin SK, Agarwal SR. Gastric varices and portal hypertensive gastropathy. Clin Liver Dis 2001; 5: 727-767
• 22 Roman S, Saurin JC, Dumortier J et al. Tolerance and efficacy of argon plasma coagulation for controlling bleeding in patients with typical and atypical manifestations of watermelon stomach. Endoscopy 2003; 35: 1024-1028
• 23 Herrera S, Bordas JM, Liach J et al. The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in patients admitted for GI hemorrhage. Gastrointest Endosc 2008; 68: 440-446
• 24 Hou MC, Lin HC, Chen CH et al. Changes in portal hypertensive gastropathy after endoscopic variceal sclerotherapy or ligation. An endoscopic observation. Gastrointest Endosc 1995; 42: 139-144
• 25 Lo GH, Lai KH, Cheng JS et al. The effects of endoscopic variceal ligation and propranolol on portal hypertensive gastropathy: a prospective, controlled trial. Gastrointest Endosc 2001; 53: 579-584