The role of propranolol in congestive gastropathy of portal hypertension

Abstract

Heavy diffuse bleeding from congested gastric mucosa (congestive gastropathy) was treated by propranolol (dose = 24 to 480 mg per day) in 14 consecutive patients with portal hypertension. Thirteen patients (93%) stopped bleeding within 3 days. Gastric mucosal cherry red spots (a sign of severe gastropathy) were unchanged in 5 patients, became less obvious in 4 and appearances returned to normal in 5. Propranolol was discontinued electively in seven patients after 2 to 6 months; four of these patients rebled from the same lesion and stopped bleeding when propranolol was recommenced. No patient has rebled from congestive gastropathy while receiving propranolol during follow-up of 12 to 42 (median = 23) months. A further 24 patients with nonbleeding congestive gastropathy received 160 mg long-acting propranolol per day in a double-blind placebo controlled cross-over trial. Twenty-two patients completed the study; in nine patients, endoscopic grading of congestive gastropathy improved after propranolol compared to three after placebo (p less than 0.05). Although the mechanism of action is not understood, propranolol appears to have a clinically significant role in the management of nonvariceal gastric bleeding in portal hypertension.

Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy

“…Bleeding stopped within 3 d in 13 (93%) of 14 patients with portal hypertension administered propranolol in one study [101] . None of these patients rebled while receiving propranolol during a median of 23 mo of follow-up, but 4 out of 7 patients rebled after electively discontinuing propranolol therapy [104] . Nonresponse to β-adrenergic receptor antagonists, defined as continued bleeding despite this therapy and transfusion-dependency despite iron replacement therapy, should prompt consideration of interventional therapies [214] .…”

“…Table 5 [8, 9,11,14,34,41,55,62,67,71,83,85] lists wellestablished risk factors for PHG; Table 6 [11,41, 44,55,[75][76][77]83,85,[98][99][100][101][102][103][104][105][106][107] lists therapies that affect the severity of PHG or the risk of bleeding from PHG, and Table 7 [8, 14,28,30,35,42,84,[108][109][110] lists the factors that do not affect the risk of PGH.…”

“…β-adrenergic receptor antagonists: Nonselective β-adrenergic receptor antagonists reduce portal pressure and gastric mucosal blood flow, and thereby reduce bleeding from PHG [103,104,132,191,[222][223][224] . Several studies evaluated the efficacy of propranolol, a nonselective β-adrenergic receptor antagonist in primary and secon- dary prevention of bleeding from PHG [104,225] .…”

“…β-adrenergic receptor antagonists: Nonselective β-adrenergic receptor antagonists reduce portal pressure and gastric mucosal blood flow, and thereby reduce bleeding from PHG [103,104,132,191,[222][223][224] . Several studies evaluated the efficacy of propranolol, a nonselective β-adrenergic receptor antagonist in primary and secon- dary prevention of bleeding from PHG [104,225] . Pérez-Ayuso et al [103] reported in a multi-center, randomized, controlled trial of 57 patients with acute or chronic bleeding from severe PHG with cirrhosis that the 26 patients administered propranolol at 20-160 mg twice daily rebled significantly less frequently than the 31 controls receiving only iron therapy as needed at 12 mo (38% vs 65%; P < 0.05), and at 30 mo follow-up (7% vs 52%, P < 0.05).…”

Gastric Antral Vascular Ectasia and Portal Hypertensive Gastropathy

“…A meta-analysis established that target HVPG is a valid marker to monitor drug eicacy for variceal bleeding and patient prognosis [65]. Beta blockers are irst-line drugs used to reduce portal pressure and have the most beneit in patients with mild PHG [66]. Modest efects have been noted in patients with severe PHG [67].…”