Portal Hypertension and Hypertensive Gastropathy Diagnosis

Endoscopic diagnostic criteria

► Hypertensive gastropathy (Fig. 3.114)

- Stippled erythema

- Edema

- Snake-skin pattern of mucosal markings

- Confluent areas of erythema

- Superficial hemorrhages

- Patchy, streaky, or reticular pattern of erythema

- Mucosal hemorrhages

- Streaks radiating toward the antrum ("watermelon stripes")

- Fragile mucosa

- Convoluted vessels protruding into the lumen, sometimes with a "cluster of grapes" appearance; mucosa over the varices may be normal, dull red, or bluish

- Encircling the cardia or fundus; sometimes found in the body and antrum, rarely in the duodenum

Differential diagnosis

► Varices/mucosal folds

► Hypertensive gastropathy/gastritis

Checklist for endoscopic evaluation

► Determine location of varices in the stomach.

► Estimate severity.

► Look for varices in the esophagus.

► Check for signs of hypertensive gastropathy.

Additional Studies

► If in doubt, endosonography can differentiate between a varix and a thick fold of mucosa (Fig. 3.117).

d Varicose venous dilatation in the stomach due to portal hypertension, with signs of fresh hemorrhage i

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d Varicose venous dilatation in the stomach due to portal hypertension, with signs of fresh hemorrhage e Prepyloric varicose gastric veins f Antral varix due to portal vein thrombosis in a patient with pancreatic carcinoma

■ Special Considerations

The operated stomach is a challenge for the endoscopist in two respects: First, anatomical orientation is difficult and often the stomach is difficult to examine. Second, different types of resections are associated with different complications, some of which are detectable by endoscopy. It is important for the examiner to know the prior history, therefore (Tables 3.23, 3.24).

Table 3.23 stomach

Information needed before examining the operated

► Reason for the operation: benign/malignant disease

► Date of the operation

► Type of resection performed

Table 3.24 Types of surgery most commonly seen by endoscopists

► Total gastrectomy

► Partial gastrectomy

► Vagotomy with or without pyloroplasty

► Fundoplication

Complications that arise in association with gastric operations can be classified as early (perioperative) or late (Table 3.25).

Table 3.25 Complications following gastric surgery

■ Systematic Examination

As in the nonoperated stomach, endoscopy of the postsurgical stomach should follow a systematic routine. The gastroe-sophageal junction, gastric remnant, anastomosis, and afferent and efferent loops are inspected, and the fundus and cardia are examined in retroflexion (Fig. 3.118).

Early complications

► Detectable by endoscopy

- Hemorrhage

- Anastomotic stenosis

► Not detectable by endoscopy

- Gastric atony

- Anastomotic leak

Late complications

Detectable by endoscopy

- Recurrence of the underlying disease: carcinoma, ulcer

- Obstruction: postoperative stenosis, stricture due to ulcer scarring, occasional efferent loop syndrome

- Bezoars

- Suture remnants

- Reflux-induced complications: alkaline reflux esophagitis, alkaline reflux gastropathy

- Anastomotic ulcer

- Anastomositis

- Gastric remnant carcinoma

Not detectable by endoscopy

- Dumping syndrome (early and late)

- Metabolic deficiency states: iron deficiency, calcium deficiency, vitamin B12 deficiency, vitamin D deficiency

Fig. 3.118a - f Systematic examination of the operated stomach

Fig. 3.118a - f Systematic examination of the operated stomach

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