Portal Hypertensive Gastropathy

Definition

• Gastric vascular changes associated with portal hypertension

Diagnostic Criteria

• Dilated, tortuous vessels in submucosa of gastric body
  • May not be visible on shallow biopsy specimens
  • Mucosal vascular distension
  • Nearly always associated with portal hypertension due to cirrhosis
• Endoscopic appearance
• Cherry red spots
• May resemble scarlatina rash
• White reticular pattern
• May resemble snakeskin
• Mosaic appearance in proximal stomach
• Responds to lowering of portal pressure

Robert V Rouse MD
Department of Pathology
Stanford University School of Medicine
Stanford CA 94305-5342

Original posting/updates : 9/9/09, 4/16/10

Differential Diagnosis

Classification / Lists

Gastritis / Gastropathy

• Reactive gastropathy / chemical gastritis
  • Includes most acute gastritis
  • Various causes including:
    • Alcohol
    • NSAIDS and other drugs
    • Bile and/or duodenal contents (alkaline) reflux
      • Frequently post-surgical
• Chronic gastritis and chronic active gastritis
  • Non-atrophic, predominantly antral
    • Includes Helicobacter-associated chronic active gastritis
    • Late stages may have multi-focal atrophy
  • Atrophic, fundic
    • Autoimmune
• Other drug related gastritis
  • Iron
    • Stainable iron crystalline material present
  • Aluminum based antacids (gastric mucosal calcinosis)
    • Small, pink, partially calcified. refractile crystals
  • Kayexalate
    • Rhomboid or triangular, non-polarizable basophilic crystals
  • Chemotherapy
  • See excellent reviews
    • Parfitt and Driman, Hum Pathol 2007, 38:927
    • Srivastava and Lauwers, Histopathol 2007, 50:15
• Hypertrophic/hyperplastic gastritis
  • Menetrier disease
  • Zollinger Ellison syndrome
• Special types
  • Collagenous
  • Lymphocytic
  • Eosinophilic gastroenteritis
  • Granulomatous
• Vascular
  • Gastric vascular antral ectasia (GAVE)
  • Portal hypertensive gastropathy
  • Ischemic
• Infectious
  • Helicobacter
  • Viral
  • Fungal
  • Parasitic

Bibliography

• Noffsinger A, Fenoglio-Preiser CM, Maru D, Gilinisky N.  Gastrointestinal Diseases, AFIP Atlas of Nontumor Pathology, First Series, Fascicle 5, 2007.
• Vesoulis Z, Naik N, Maseelall P. Histopathologic changes are not specific for diagnosis of gastric antral vascular ectasia (GAVE) syndrome: a review of the pathogenesis and a comparative image analysis morphometric study of GAVE syndrome and gastric hyperplastic polyps. Am J Clin Pathol. 1998 May;109(5):558-64.
• Gretz JE, Achem SR. The watermelon stomach: clinical presentation, diagnosis, and treatment. Am J Gastroenterol. 1998 Jun;93(6):890-5.
• Srivastava A, Lauwers GY. Pathology of non-infective gastritis.Histopathology. 2007 Jan;50(1):15-29.
• Westerhoff M, Tretiakova M, Hovan L, Miller J, Noffsinger A, Hart J. CD61, CD31, and CD34 improve diagnostic accuracy in gastric antral vascular ectasia and portal hypertensive gastropathy: An immunohistochemical and digital morphometric study. Am J Surg Pathol. 2010 Apr;34(4):494-501.