Management of portal hypertensive gastropathy

Clinical scenario	Therapies to decrease portal hypertension	Management of anemia/blood loss	Comments
Primary prophylaxis	Nonselective beta blocker^* titrated to HR of 50 to 55 BPM or highest tolerated dose, eg: Propranolol 20 mg orally twice daily (maximum 160 mg twice daily) or Nadolol 40 mg orally once daily (maximum 160 mg daily) or Carvedilol starting at 3.25 mg orally twice daily (maximum 25 mg twice daily) is an alternative to nonselective beta blockers	N/A	Data supporting primary prophylaxis are lacking. We provide prophylaxis for the following patients: Patients with severe portal hypertensive gastropathy and other risk factors for bleeding (eg, a coagulopathy or thrombocytopenia) Patients with portal hypertensive gastropathy and varices
Chronic bleeding	Nonselective beta blocker^* titrated to HR of 50 to 55 BPM or highest tolerated dose, eg: Propranolol 20 mg orally twice daily (maximum 160 mg twice daily) or Nadolol 40 mg orally once daily (maximum 160 mg daily) or Carvedilol starting at 3.25 mg orally twice daily (maximum 25 mg twice daily) is an alternative to nonselective beta blockers	Iron repletion^¶ Blood transfusion if hemoglobin <7 to 8 g/dL^Δ	The nonselective beta blocker should be continued indefinitely
Acute bleeding	Vasoactive medication, eg: Octreotide 100 mcg IV bolus followed by an infusion of 25 mcg/hour for two to five days or Somatostatin^◊ 250 mcg IV bolus followed by an infusion of 250 mcg/hour for three days or Terlipressin^§ 2 mg IV every four hours initially, then titrated down to 1 mg IV every four hours for up to five days	Resuscitation with IV fluids and blood transfusion to maintain hemoglobin between 7 and 8 g/dL in patients with cirrhosis, or ≥8 g/dL in patients without cirrhosis	Patients with cirrhosis should also receive antibiotic prophylaxis for SBP for seven days^¥, eg: Ceftriaxone 1 gram IV daily Ciprofloxacin 500 mg orally twice daily or Ciprofloxacin 400 mg IV twice daily or Trimethoprim-sulfamethoxazole 1 DS tablet orally twice daily or Norfloxacin^◊ 400 mg orally twice daily Once the acute bleeding episode is resolved, patients should be started on secondary prophylaxis with a nonselective beta blocker
Refractory bleeding (chronic or acute)	Shunt therapy: TIPS Surgical shunt Liver transplantation Endoscopic treatment/APC if a focal lesion is present	As above	Patients with chronic bleeding who respond appropriately to iron repletion or transfusion may be managed expectantly
Secondary prophylaxis	Nonselective beta blocker^* titrated to HR of 50 to 55 BPM or highest tolerated dose, eg: Propranolol 20 mg orally twice daily (maximum 160 mg twice daily) or Nadolol 40 mg orally daily (maximum 160 mg daily) or Carvedilol starting at 3.25 mg orally twice daily (maximum 25 mg twice daily) is an alternative to nonselective beta blockers	N/A	The nonselective beta blocker should be continued indefinitely

Antibiotic doses shown are for use in patients with normal renal function. Some agents require dose adjustment in patients with renal impairment.

APC: argon plasma coagulation; BPM: beats per minute; DS: double strength (ie, trimethoprim 160 mg and sulfamethoxazole 800 mg per tablet); HR: heart rate; IV: intravenous; N/A: not applicable; SBP: spontaneous bacterial peritonitis; TIPS: transjugular intrahepatic portosystemic shunt.

* Provided there are no contraindications to beta blocker therapy. Patients who cannot take or do not tolerate nonselective beta blockers or carvedilol are treated like those with refractory bleeding.

¶ Refer to UpToDate topics on treatment of iron deficiency for details on methods for iron repletion.

Δ The decision to transfuse blood is complicated and depends on multiple different variables, including the presence of underlying cardiac disease, the acuity and volume of bleeding, the presence of cirrhosis, and other variables. In those with cirrhosis, the target hemoglobin is typically 7 to 8 g/dL. Refer to UpToDate topics on the management of upper gastrointestinal bleeding for details.

◊ Not available in the United States.

§ In the United States, gastrointestinal bleeding is an off-label indication.

¥ Refer to UpToDate topics on the management of variceal hemorrhage for detailed discussions of antibiotic selection and administration.

References:

Urrunaga NH, Rockey DC. Portal hypertensive gastropathy and colopathy. Clin Liver Dis 2014; 18:389.
Kaplan DE, Ripoll C, Thiele M, et al. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024; 79:1180.
Khalifa A, Rockey DC. Role of Endoscopy in the diagnosis, grading, and treatment of portal hypertensive gastropathy and gastric antral vascular ectasia. Gastrointest Endosc Clin N Am 2024; 34:263.

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Management of portal hypertensive gastropathy