Overview
Definition:
Portal hypertensive colopathy (PHC) refers to a spectrum of colonic mucosal abnormalities, ranging from edema and vascular ectasia to erosions and ulcers, occurring in patients with portal hypertension, typically secondary to liver cirrhosis.
Epidemiology:
The prevalence of PHC varies significantly in literature, ranging from 20% to 70% in patients with cirrhosis, depending on the diagnostic method and definition used
It is more common in patients with advanced liver disease and higher portal pressures.
Clinical Significance:
PHC is an important cause of lower gastrointestinal bleeding in patients with portal hypertension, which can be severe and difficult to manage
Understanding its surgical implications is crucial for preventing and treating bleeding episodes and optimizing patient outcomes, especially in those awaiting or undergoing liver transplantation.
Clinical Presentation
Symptoms:
Hematochezia (often painless, intermittent, or chronic)
Melena may occur with proximal colonic lesions
Abdominal pain is less common but can be present
Symptoms of underlying liver disease (jaundice, ascites, encephalopathy).
Signs:
Signs of chronic liver disease: jaundice, ascites, splenomegaly, caput medusae, spider angiomas
Rectal examination may reveal signs of bleeding or associated hemorrhoids
Vital signs may indicate hypovolemia if significant bleeding occurs.
Diagnostic Criteria:
There are no universally established diagnostic criteria for PHC
Diagnosis is typically made endoscopically based on characteristic mucosal findings in a patient with known portal hypertension and exclusion of other causes of colitis or bleeding.
Diagnostic Approach
History Taking:
Detailed history of liver disease (etiology, duration, severity), previous gastrointestinal bleeding episodes, alcohol consumption, medications (NSAIDs, anticoagulants), and presence of ascites or encephalopathy
Assess severity of bleeding.
Physical Examination:
Thorough abdominal examination for hepatomegaly, splenomegaly, ascites, and collateral circulation
General examination for stigmata of chronic liver disease
Digital rectal examination to assess for rectal pathology and blood.
Investigations:
Laboratory: Complete blood count (anemia, thrombocytopenia), liver function tests, coagulation profile (INR, PTT), electrolytes, renal function
Imaging: Abdominal ultrasound with Doppler (assess portal vein patency, spleen size, ascites), CT angiography or MR angiography (evaluate portal venous system, identify bleeding sites)
Endoscopy: Colonoscopy is the gold standard for diagnosis, visualizing mucosal changes (edema, vascular ectasia, erosions, ulcers) and identifying the source of bleeding
Biopsies may be taken but are often non-specific.
Differential Diagnosis:
Inflammatory bowel disease (Crohn's disease, ulcerative colitis)
Ischemic colitis
Radiation proctocolitis
Infectious colitis
Diverticular disease
Angiodysplasia
Malignancy
Hemorrhoids
Upper gastrointestinal bleeding.
Surgical Management
Indications:
Refractory or recurrent severe gastrointestinal bleeding not amenable to endoscopic or medical management
Hemodynamic instability due to bleeding
Need for definitive management prior to or after liver transplantation.
Preoperative Preparation:
Optimizing liver function and coagulopathy
Correction of anemia and thrombocytopenia
Management of ascites and hepatic encephalopathy
Nutritional support
Consultation with hepatologists and transplant surgeons if applicable
Risk stratification (e.g., MELD score).
Surgical Procedures:
Surgical options are reserved for severe, intractable bleeding and are aimed at reducing portal pressure or diverting/excising the diseased colonic segment
Procedures include: Mesocaval shunt (interposition graft), Portocaval shunt (direct anastomosis), Distal splenorenal shunt (Warren shunt), Distal colectomy with or without anastomosis, and strictureplasty for localized disease
In select cases, embolization of varices or feeding arteries may be considered.
Postoperative Care:
Close hemodynamic monitoring
Management of potential complications of shunting procedures (hepatic encephalopathy, ascites, shunt thrombosis, bleeding)
Nutritional support
Pain management
Early mobilization
Monitoring of liver function
Wound care.
Complications
Early Complications:
Bleeding from surgical site
Shunt thrombosis
Hepatic artery thrombosis (after transplant)
Ascites
Hepatic encephalopathy
Sepsis
Anastomotic leak.
Late Complications:
Shunt dysfunction or thrombosis
Progressive liver dysfunction
Recurrent bleeding from other sites
Development of hepatocellular carcinoma
Bowel obstruction
Portopulmonary hypertension.
Prevention Strategies:
Careful patient selection and optimization of liver function
Meticulous surgical technique
Prophylactic antibiotics
Aggressive management of coagulopathy and thrombocytopenia
Close postoperative monitoring
Multidisciplinary approach involving surgeons, hepatologists, and intensivists.
Prognosis
Factors Affecting Prognosis:
Severity of underlying liver disease (MELD score)
Extent and severity of colonic involvement
Type and success of surgical intervention
Presence of complications
Patient's overall health status.
Outcomes:
Outcomes are variable and depend heavily on the patient's underlying liver disease
Shunting procedures can control bleeding but may worsen hepatic encephalopathy or ascites
Resectional surgery may be definitive for bleeding but carries significant morbidity in cirrhotic patients
Outcomes are generally poorer in patients with decompensated cirrhosis.
Follow Up:
Long-term follow-up is essential to monitor for shunt patency, recurrence of bleeding, development of new complications, and progression of liver disease
Regular liver function tests, imaging of the portal venous system, and clinical assessments are required.
Key Points
Exam Focus:
PHC is a complication of portal hypertension, leading to colonic mucosal changes and bleeding
Colonoscopy is diagnostic
Surgical management is reserved for refractory bleeding and involves shunting or resection, with significant risks in cirrhotic patients.
Clinical Pearls:
Always consider PHC in patients with cirrhosis and lower GI bleeding
Distinguish from other causes of colitis
Optimize liver function before any surgical intervention
Multidisciplinary management is key, especially in transplant candidates.
Common Mistakes:
Attributing all lower GI bleeding in cirrhotic patients to varices without thorough endoscopic evaluation
Underestimating the risks of surgery in decompensated cirrhosis
Delaying definitive management in cases of severe, recurrent bleeding.