TREATMENT OF BLEEDING FROM PORTAL HYPERTENSIVE GASTROPATHY BY PORTACAVAL-SHUNT

Portal hypertensive gastropathy is a vascular disorder of the gastric mucosa distinguished by ectasia of the mucosal capillaries and submuco sal veins without inflammation. During 1988 to 1993, 12 patients with biopsy-proven cirrhosis (10 alcoholic, 2 posthepatitic) were evaluated and treated prospectively by portacaval shunt for active bleeding fro m severe portal hypertensive gastropathy. Eleven patients had been hos pitalized for bleeding three to nine times previously, and one was ble eding uncontrollably for the first time. Requirement for blood transfu sions ranged from 11 to 39 units cumulatively, of which 8 to 30 units were required specifically to replace blood lost from portal hypertens ive gastropathy. Admission findings were ascites in 9 patients, jaundi ce in 8, severe muscle wasting in 10, hyperdynamic state in 9. Child's risk class was C in 7, B in 4, A in 1. Ten of the 12 patients had pre viously received repetitive endoscopic sclerotherapy for esophageal va rices, which has been reported to precipitate portal hypertensive gast ropathy. Eight patients had failed propranolol therapy for bleeding. P ortacaval shunt was performed emergently in 11 patients and electively in 1, and permanently stopped bleeding in all by reducing the mean po rtal vein-inferior vena cava pressure gradient from 251 to 16 mm salin e. There were no operative deaths, and two unrelated late deaths after 13 and 24 months, During 1 to 6.75 years of follow-up, all shunts rem ained patent by ultrasonography, the gastric mucosa reverted to normal on serial endoscopy, and there was no gastrointestinal bleeding. Recu rrent portal-systemic encephalopathy developed in only 8% of patients. Quality of Life was generally good. It is concluded that portacaval s hunt provides definitive treatment of bleeding portal hypertensive gas tropathy by eliminating the underlying cause, and makes possible prolo nged survival with an acceptable quality of life.