Other nonneoplastic

Portal hypertensive gastropathy

Editorial Board Members: Aaron R. Huber, D.O., Wei Chen, M.D., Ph.D.
Mohamed Yakoub, M.D.
Divya Sharma, M.D.

Last author update: 9 May 2023
Last staff update: 9 May 2023

Copyright: 2002-2023,, Inc.

PubMed Search: Portal hypertensive gastropathy

Mohamed Yakoub, M.D.
Divya Sharma, M.D.
Page views in 2022: 7,169
Page views in 2023 to date: 3,674
Cite this page: Yakoub M, Sharma D. Portal hypertensive gastropathy. website. Accessed June 2nd, 2023.
Definition / general
  • Portal hypertensive gastropathy (PHG) refers to the pathologic effects of increased portal venous pressure on the mucosal surface of the stomach
Essential features
  • Portal hypertensive gastropathy is mainly a clinical and endoscopic diagnosis; histologic findings should be correlated with the clinical diagnosis
  • Histologic features are nonspecific and show congested capillaries and venules in the gastric mucosa, mainly in the body and fundus, without significant inflammation or fibrin thrombi
  • Congestive gastropathy: historic term first described by McCormack et al. in 1985 (Gut 1985;26:1226)
ICD coding
  • ICD-10: K31.89 - other diseases of stomach and duodenum
  • 20 - 98% prevalence in patients with liver cirrhosis (Gastroenterology 2000;119:181)
  • Wide range of prevalence is related to the variability of the characterization criteria of the disease
  • Risk factors:
    • Schistosomiasis
    • Heart failure
  • Poorly understood
  • Portal hypertension: increased pressure in high resistance venous system
  • Backing up of blood in the collateral circulation of the gastrointestinal tract, including the proximal stomach (venous congestion and bleeding)
  • Vascular and mucosal changes in the stomach
  • Additional theories include mucosal injury, hypoxia, cytokine production and inflammation (Gastroenterology 1992;102:2066)
  • Portal hypertension:
    • Increased sinusoidal and portal venous pressure (cirrhosis)
    • Presinusoidal diseases, like portal vein thrombosis and veno-occlusive disorders
    • Postsinusoidal etiology, like heart failure
  • No well documented correlation between severity of portal hypertension and development of portal hypertensive gastropathy (Gastroenterology 1992;102:994)
Clinical features
  • Patients with portal hypertensive gastropathy usually present with chronic gastrointestinal bleeding that can result in iron deficiency anemia (Gastroenterology 2000;119:181)
  • Acute gastrointestinal bleeding is less common
  • Portal hypertensive gastropathy can be associated with esophageal varices
  • Classification systems are based on endoscopic findings
  • Clinical: association with cirrhosis
  • Upper gastrointestinal endoscopy (i.e., EGD) findings:
    • Mild cases: snake skin, mosaic-like pattern of stomach mucosa
    • Severe cases: bulging red to brown marks
    • Specificity of endoscopic findings for portal hypertensive gastropathy diagnosis were reported as follows (World J Gastrointest Endosc 2013;5:323):
      • Mosaic-like pattern: 100% sensitivity and 92% specificity
      • Red point lesions: 48% sensitivity and 91% specificity
      • Cherry red spots: 39% sensitivity and 96% specificity
      • Confluent red marks: 22% sensitivity and 100% specificity
  • Capsule endoscopy:
  • Radiologic findings (double contrast upper gastrointestinal imaging study):
Radiology description
Radiology images

Images hosted on other servers:

Gastric serpentine mucosal folds

Prognostic factors
  • Poor prognosis is associated with severe cases presenting with acute bleeding
  • Rarely fatal bleeding has been reported (J Clin Diagn Res 2016;10:HD01)
  • Cirrhotic patients with severe portal hypertensive gastropathy associated with higher portal pressure had worse prognosis than patients with mild portal hypertensive gastropathy (Dig Dis Sci 2010;55:3561)
Case reports
  • Iron supplementation for chronic gastrointestinal bleeding
  • Beta blockers and octreotide to decrease portal blood pressure
  • Transjugular intrahepatic portosystemic shunt (TIPS) procedure (Hepatology 1995;21:1011)
  • Endoscopic therapy (sclerotherapy or coagulation therapy):
Clinical images

Contributed by Michael Schoech, M.D.

Endoscopy: mosaic-like pattern

Microscopic (histologic) description
  • No specific histologic diagnostic criteria for portal hypertensive gastropathy
  • Histologic diagnosis is correlated with clinical history (portal hypertension) and endoscopic findings
  • Prominent congested blood vessels (capillaries and venules) in the lamina propria
  • Lamina propria edema or fibrosis
  • Congested, dilated and tortuous mucosal and submucosal venules (Gut 1985;26:1226)
  • Features of reactive gastropathy can be seen
  • The above features can only be seen in the submucosa; with variable degrees, a normal gastric biopsy does not exclude the clinical diagnosis of portal hypertensive gastropathy (Am J Clin Pathol 2022;158:632)
  • Absence of significant inflammation and fibrin thrombi
Microscopic (histologic) images

Contributed by Divya Sharma, M.D.

Congestion and reactive gastropathy

Congested blood vessels

Lamina propria fibrosis

Ectatic blood vessels

Sample pathology report
  • Stomach, biopsy:
    • Portal hypertensive gastropathy (see comment)
    • Comment: Mild reactive gastropathy with mucosal congestion and dilated vessels within lamina propria is consistent with portal hypertensive gastropathy.
    • Negative for intestinal metaplasia, dysplasia or malignancy.
Differential diagnosis
Board review style question #1
A 58 year old man with a history of hepatitis C cirrhosis and prior bleeding varices presented with chronic chest pain, dyspepsia and anemia. Esophagogastroduodenoscopy (EGD) showed mucosal red spots in the stomach fundus. Which of the following histologic features is expected to be noted on biopsy?

  1. Active chronic inflammation
  2. Congested capillaries in the lamina propria without significant inflammation
  3. Ectatic blood vessels and fibrin thrombi
  4. Extensive intestinal metaplasia
Board review style answer #1
B. Congested capillaries in the lamina propria without significant inflammation. The clinical history suggests portal hypertension (cirrhosis and bleeding varices), which raises concern of portal hypertensive gastropathy. EGD findings show mucosal red spots or mosaic pattern that support the diagnosis.

Comment Here

Reference: Portal hypertensive gastropathy
Board review style question #2

The figure above is from a stomach biopsy in a 63 year old woman with history of recurrent deep vein thrombosis. Esophagogastroduodenoscopy (EGD) shows mosaic-like pattern of the stomach mucosa without bleeding. Which of the following is a possible etiology of the endoscopic findings?

  1. Atrophic gastritis
  2. Chronic hypertension
  3. Inflammatory bowel disease
  4. Portal vein thrombosis
Board review style answer #2
D. Portal vein thrombosis. The patient history and the EGD findings of the stomach suggest portal hypertension due to veno-occlusive disorder. Portal vein thrombosis can result in backing up of collateral circulation in the upper gastrointestinal tract causing portal hypertensive gastropathy. The biopsy of the stomach shows diffuse congestion of mucosal capillaries, supporting portal hypertensive gastropathy.

Comment Here

Reference: Portal hypertensive gastropathy
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