S5635 A Common Problem With a Rare Treatment

Introduction: Portal hypertension is a life-threatening complication of hepatic cirrhosis and a leading cause of hospitalization, liver transplantation, and mortality. Among its well-documented complications are variceal hemorrhage and portal hypertensive gastropathy (PHG), both major causes of upper gastrointestinal bleeding. A lesser-known, incompletely characterized manifestation of portal hypertension is portal hypertensive associated polyps (PHAPs). Although their natural history is unclear and they often present asymptomatically, PHAPs have been linked to gastrointestinal bleeding, iron deficiency anemia (IDA), and pyloric obstruction. Due to their clinically significant rarity, no standardized treatment guidelines exist. Therapies such as argon plasma coagulation (APC), resection, and polypectomy have been used, but recurrence is comm. Case Description/Methods: We present a case of a 60-year-old woman with cirrhosis secondary to metabolic dysfunction-associated steatotic liver disease (MASLD), PHG, and severe, refractory IDA attributed to PHAP’s. Before arriving at our clinic, she was initially diagnosed with nodular gastric antral vascular ectasia and was unsuccessfully treated with endoscopic band ligation, cauterization, iron infusions, blood transfusions, and erythropoiesis-stimulating agents. Subsequent endoscopy revealed multiple large, semi-pedunculated antral polyps. The polyps were resected via endoscopic mucosal resection and APC was applied to areas of active and non-bleeding mucosa. Despite this, her anemia persisted, prompting transjugular intrahepatic portosystemic shunt (TIPS) placement with embolization of the coronary and short gastric veins. Continued melena and hemodynamic instability required TIPS revision and angioplasty 2 weeks later. Four months post-procedure, ongoing bleeding necessitated transhepatic TIPS access, recanalization, and serial balloon dilations. Despite placement of 4 stents and repeated endoscopic interventions including APC, her bleeding recurred. More than 50 units of PRBC’s were transfused over time. Due to high surgical risk for antrectomy, the right gastroepiploic artery was embolized. Follow-up endoscopy 2 months later showed improvement and was transfusion dependent. Discussion: Severe nodular portal hypertensive gastropathy is a distinct entity from GAVE and TIPS is a viable option. Rarely this entity doesn’t respond to TIPS and right gastroepiploic artery embolization is a viable but rare option.