Dig Dis Sci (2014) 59:10361041

DOI 10.1007/s10620-014-3036-3

ORIGINAL ARTICLE

Portal Hypertensive Enteropathy Diagnosed by Capsule

Endoscopy in Cirrhotic Patients: A Nationwide Multicenter Study
Seong Ran Jeon Jin-Oh Kim Ji-Beom Kim Byong Duk Ye Dong Kyung Chang
Ki-Nam Shim Dae Young Cheung Jin Soo Kim Myung Gyu Choi
Hyun Joo Song Yun Jeong Lim Soo Jung Park Ji Hyun Kim
Jeong Seop Moon Yoon Tae Jeen The Korean Gut Image Study Group

Received: 27 November 2013 / Accepted: 8 January 2014 / Published online: 4 February 2014
Springer Science+Business Media New York 2014

Abstract
Background and Aim Due to the limited data on portal
hypertensive enteropathy (PHE), the prevalence of and
clinical factors related to PHE remain unclear. This study
determined the prevalence of PHE using capsule endoscopy (CE) and PHE-related clinical factors.
Methods This was a retrospective multicenter study
using
the Capsule Endoscopy Nationwide Database Registry.
From 2,879 cases that underwent CE, 45 cirrhosis
patients
with portal hypertension (PH) were enrolled and divided
into PHE (n = 18) and non-PHE (n = 27) groups. From
computed tomography (CT) images, six secondary
changes
due to PH were scored to give a total CT score of 06.
The

S. R. Jeon J.-O. Kim (&)

Department of Internal Medicine, Soonchunhyang University
College of Medicine, 22 Daesagwan-Gil, Yongsan-Gu,
Seoul 140-743, Korea
e-mail: jokim@schmc.ac.kr
J.-B. Kim B. D. Ye
Department of Internal Medicine, University of Ulsan College of
Medicine, Seoul, Korea
D. K. Chang
Department of Internal Medicine, Sungkyunkwan University
School of Medicine, Seoul, Korea
K.-N. Shim
Department of Internal Medicine, Ewha Womans University
School of Medicine, Seoul, Korea
D. Y. Cheung J. S. Kim M. G. Choi
Department of Internal Medicine, The Catholic University
College of Medicine, Seoul, Korea
H. J. Song
Department of Internal Medicine, Jeju National University
School of Medicine, Cheju, Korea

123

main outcome variable was the prevalence of PHE and

PHE-related clinical factors.
Results The prevalence of PHE was 40 %. Comparing
the PHE and non-PHE groups, the most common ndings
were angiodysplasias in 55.7 % (vs. 7.4 %, p = 0.001) and
varices in 38.9 % (vs. 0 %, p = 0.001). Active bleeding
was observed in 16.6 and 3.7 %, respectively, but this
difference was not signicant. In the univariate analysis,
ChildTurcottePugh class C (p = 0.002) and a high CT
score (C3 vs. \3, p = 0.004) were signicantly associated
with PHE. However, only a high CT score was signicant
in the multivariate analysis (odds ratio 11.19; 95 % condence interval, 1.59-innity; p = 0.040).

Dig Dis Sci (2014) 59:10361041

Conclusions The prevalence of PHE was 40 %, and it

might be more prevalent in cirrhosis patients with PH
who
have a high CT score. CE is a useful diagnostic tool for
evaluating PHE in cirrhosis patients with PH.
Keywords Capsule endoscopy Enteropathy Portal
hypertension Liver cirrhosis

Introduction
Portal hypertensive enteropathy (PHE) is a mucosal
abnormality of the small bowel that is observed in
cirrhosis
patients with portal hypertension (PH) [1]. Although
prognosis-related major bleeding of PH generally originates from esophageal (EV) or gastric varices (GV), PHE
can lead to gastrointestinal (GI) bleeding or anemia in
cirrhosis patients [2]. As the small bowel is difcult to
approach from either the mouth or anus, it is difcult to
evaluate the entire small bowel using upper and lower
GI
endoscopy. Consequently, endoscopic abnormalities in
the
small bowels of patients with PH have not been well
characterized [3]. The introduction of capsule
endoscopy
(CE) and double-balloon enteroscopy (DBE) has made it
possible to detect these abnormalities.
The mucosal abnormalities of PHE are dened as
mucosal
inammatory-like abnormalities and vascular lesions
[1].
Summarizing previous studies, the most common
indication
for CE is obscure GI bleeding (OGIB), which is dened as
bleeding from an unknown origin that persists or recurs
after
negative upper and lower endoscopy [4]. The reported
prevalence of PHE is 65.792.8 % in cirrhosis patients,
which is higher than that in control groups [1, 57];
however,

Y. J. Lim
Department of Internal Medicine, Dongguk University College
of Medicine, Goyang, Korea
S. J. Park
Department of Internal Medicine, Yonsei University College of
Medicine, Seoul, Korea
J. H. Kim
Department of Internal Medicine, Inje University College of
Medicine, Busan, Korea
J. S. Moon
Department of Internal Medicine, Inje University College of
Medicine, Seoul, Korea

Y. T. Jeen
Department of Internal Medicine, Korea University College of
Medicine, Seoul, Korea

another study reported a frequency of only 18.2 %

[8]. In
addition, the clinical factors related to PHE are
heterogeneous, including grade 2 or greater EV, portal
hypertensive
gastropathy (PHG), portal hypertensive colopathy
(PHC),
ChildTurcottePugh (CTP) class C cirrhosis [1], and
a
history of acute GI bleeding [5].
Due to the limited data available on PHE, the
prevalence
of and clinical factors related to PHE remain unclear.
To
our knowledge, no multicenter study has examined
PHE in
cirrhosis patients with PH. Therefore, this study
determined
the prevalence of PHE using CE, and evaluated the
clinical
factors related to PHE in cirrhosis patients with PH.

Methods
Study Design and Patients
We analyzed the records in the Capsule Endoscopy
Nationwide Database Registry of cirrhosis patients
with PH

1037

who underwent CE for various reasons from October 2002

to May 2012. We conrmed the presence of liver cirrhosis
(LC) based on a physical examination, laboratory ndings,
and histological or radiological features. Cirrhosis severity
was graded according to the CTP score. PH was diagnosed
using endoscopic or radiographic evidence of esophageal,
gastric, or intra-abdominal varices, collateral circulation,
splenomegaly, secondary gall bladder wall thickening, or
ascites [3]. Exclusion criteria included the following:
underlying small bowel disease; concomitant severe cardiopulmonary disease or end-stage renal disease; user of
anticoagulant or nonsteroidal anti-inammatory drugs;
evidence of acute infection or sepsis; and lack of data.
From 2,879 CE cases, 45 that met the inclusion criteria
were enrolled in this study. These patients were divided
into those with (n = 18) and without (n = 27) PHE, and
then compared retrospectively. The data collection and
analysis were approved by each Institutional Review Board
(IRB_2012-045).
Capsule Endoscopy Procedure
Patients were examined using the PillCamTM (SB1/SB2)
(Given Imaging; Yokneam, Israel) or MiroCamTM (IntroMedic, Seoul, Republic of Korea). Written informed con-

sent was obtained from all patients before the procedure.

Either no bowel preparation was used or the bowel was
prepared according to the patients circumstances. The CE
ndings were classied as highly relevant (P2) or less
relevant (P1 or P0) lesions according to the standard
practice guidelines [9]. A result of P2 was reported as
positive. The degree of cleansing of the small bowel during
CE was scored as excellent, good, fair, or poor [10]. Then,
the quality of images was divided into acceptable (excellent, good, and fair) and non-acceptable (poor).
Classication and Denition of Endoscopic
Abnormalities
EVs were graded using the criteria proposed by Chung
et al. [11]. GVs were classied as absent or present. PHG
was classied as mild or severe according to McCormack
et al. [12]. PHC was subclassied into grades I (mild), II
(moderate), and III (severe). PHE was classied as grade I
(mucosal inammatory-like abnormalities; edema, erythema, granularity, friability) or II (vascular lesions; cherry
red spots, telangiectasia, angiodysplasia-like lesions, and
varices) [1]. Small bowel varices were dened as circumferential raised venous lesions in the small bowel that
resemble classic images of EV or GV [13]. The main
outcome variable was the prevalence of PHE based on the
CE ndings.

123

1038

Computed Tomography Findings and New Scoring

System
We identied six secondary changes due to PH on
abdominal computed tomography (CT) because the CT
ndings were too diverse to be consistent. A new
scoring
system was developed to evaluate whether the CT
ndings
were related to PHE diagnosed by CE. The six ndings
included: (1) EV or GV; (2) other collateral circulations
(i.e., periumbilical varices); (3) PHG or PHC; (4) portal
hypertensive cholecystopathy; (5) splenomegaly; and
(6)
ascites. Each of these six ndings was worth one point.
The
points were totaled to give a score from 0 to 6 points.
We
analyzed whether the CT score and various clinical
factors
were related to PHE between the PHE and non-PHE
groups.
Statistical Analysis
The statistical analyses were performed using SPSS vs.
14.0 (SPSS, Chicago, IL) and SAS vs. 9.2 (SAS, Cary,
NC). All continuous variables were compared using a
two-

Dig Dis Sci (2014) 59:10361041

Table 1 Clinical characteristics of the portal hypertensive enteropathy and non-portal hypertensive enteropathy groups
Variable

PHE

Non-PHE

Patients (%)

18 (40.0)

27 (60.0)

Age (mean SD; year)

57.3 10.1 56.4 14.1 0.811

Male (%)

12 (66.7)

21 (77.8)

HCV

7
3

10
4

Alcohol

Others

Etiology of cirrhoisis
HBV

0.499
0.713

Comorbidities

0.767

Diabetes mellitus
Hypertension
Pulmonary tuberculosis

Hepatocellular carcinoma 3

Previous bleeding history

History of

(%)

endoscopic 5 (62.5)

8 (44.4)

13 (48.1)
4 (30.7)

Esophageal variceal bleeding

1 (12.5)

2 (15.3)

Small bowel bleeding

2 (25.0)

7 (54.0)

Other

5 (62.5)

3 (23.0)

0.592

0.807
intervention (%)a
tailed Students t test. All categorical variables were
compared using Fishers exact test. Multivariate
Lowest Hb (mean SD,
g/dL)
analysis
was conducted by logistic regression. A p value of \0.05 CTP class (%)
was used as the cutoff for statistical signicance.
Class A/B

27 (100.0)
0 (0.0)

0.002b

13 (72.2)
9 (69.2)

13 (48.1)
87 (61.5)

0.904

Grade 1

3 (23.1)

4 (30.8)

Grade 2

1 (7.7)

1 (7.7)

0 (0.0)

0 (0.0)

3 (16.7)

3 (11.1)

9 (50.0)

7 (25.9)

5 (55.6)
4
4 (44.4)

4 (57.1)
3
5 (42.9)

The mean age of the 45 patients with PH was

Grade 3
57.1 13.1 years, and the dominant gender was male
Grade 4
(33/
Gastric varices
45, 73.3 %). Among these patients, the mean
Portal hypertensive
hemoglobin
gastropathy
was 7.5 1.9 g/dL, and 13.3 % (6/45) of the patients
Mild
were
Severe
CTP class C. CTP class C was signicantly more frequent Rectal varices
in the PHE group (p = 0.002). The mean CT score was Portal hypertensive
signicantly higher in the PHE group (1.8 1.4 vs.
colopathy
1.0 0.8; p = 0.027). The clinical characteristics are
Grade 1
summarized in Table 1.
Grade 2

Conventional Endoscopy and Capsule EndoscopyRelated Data

12 (66.7)
6 (33.3)

0.807

p0.132

Esophageal varices

Clinical Characteristics

7.6 1.9

22.1 35.2 10.6 9.9

Class C
Duration of symptom
(mean SD; days)

Results

7.5 1.8

0
3 (0.0)
5 (27.8)

3
5 (11.1)
4 (14.8)

3 (60.0)

0 (0.0)

1 (20.0)

2 (50.0)

1 (20.0)

2 (50.0)

1.8 1.4

1.0 0.8

0.671
0.098

0.264
0.449

0.027b

Grade 3
CT score (mean SD)

EV, GV, PHG, and PHC except rectal varices were more
frequent in the PHE group than the non-PHE group, but PHE portal hypertensive enteropathy, SD standard deviation, HBV
hepatitis B virus, HCV hepatitis C virus, Hb hemoglobin, CTP Child
the
TurcottPugh, CT computed tomography
difference was not signicant (Table 1). For the 45
Endoscopic variceal ligation and sclerotherapy
patients, the completion rate of CE was 80 % (36/45)
Denote signicant difference (p \ 0.05)
and
OGIB was the most common indication for CE (44/45,
97.7 %). In the non-PHE group, only one patient

123
Dig Dis Sci (2014) 59:10361041

1039

Table 2 Capsule endoscopic ndings of the portal hypertensive Outcome Variables Data
enteropathy and non-portal hypertensive enteropathy groups
Variable

Indication of CE
Overt OGIB
Occult OGIB
Other
Type of CE
PillCamTM (SB1/2)
MiroCamTM
Bowel preparation
NPO
PEG 2L or 4L
NaP
Acceptable quality
of images

PHE
(n = 18) (%)

The prevalence of PHE was 40 % (18/45), and vascular

lesions, except inammatory-like lesions, were detected in

Non-PHE
(n = 27) (%)
Arr

gs

iva

(P2

at

a
Ne

ce

b
gati

cu

ve

nd
ing

Re
sul

ts

of

CE

s
(P1
or
P0)
Di
a

gnostic yield

0.137
17 (94.4)
1 (5.6)

19 (70.4)
7 (25.9)

1 (3.7)
0.716

13 (72.2)
5 (27.8)

21 (80.8)
5 (19.2)

5 (27.8)
12 (66.7)

7 (25.9)
19 (70.4)

0.246

1 (5.5)

1 (3.7)

16 (88.8)

25 (92.3)

0.669

15 (88.2)

21 (77.8)

0.455
\0.001

18 (100.0)
0 (0.0)

14 (51.9)
13 (48.1)

94.4 %
(17/18).
In the
PHE
group,
the most
common
p
ndings
included
angiodys
plasia,
which
was
detected
signicantly
more
frequentl
y than in

71.1 % (32/45)
PHE portal hypertensive enteropathy, CE capsule endoscopy,
OGIB
obscure gastrointestinal bleeding, NPO nil per os, PEG
polyethylene
glycol, NaP sodium phosphate

the non-PHE group (55.7

vs. 7.4 %, p = 0.001). Varices were signicantly more
common in the PHE group (38.9 vs. 0 %, p = 0.001).
Active bleeding was more frequent in the PHE group than
the non-PHE group, but the difference was not signicant
(16.6 vs. 3.7 %, p = 0.139). The CE ndings in the small
bowel are presented in Table 3 and Fig. 1. In the univariate
analysis, CTP class C and a CT score [3 points were
signicantly associated with PHE. However, only a high
CT score was signicantly associated with PHE in the
multivariate analysis [odds ratio (OR) 11.19, 95 % condence interval (CI), 1.59-innity, p = 0.040] (Table 4).
Treatment and Clinical Outcomes
In the PHE group, the frequency of interventional therapy
showed a marginally signicant difference compared with the
non-PHE group (38.9 vs. 14.8 %, p = 0.066). In the 40
patients who were followed, the rebleeding rate was not signicantly different between the groups. For the 17 patients
with rebleeding, small bowel lesions were more common in
the PHE group than in the non-PHE group, although the difference was not signicant. During follow-up, no death due to
small bowel bleeding occurred in either group (Table 5).

Table 3 Capsule endoscopic ndings in the small bowel

Group

Finding

N (%)

PHE (n = 18)

Inammatory-like lesion
Red spots

1 (5.6)
3 (16.6)

Angiodysplasias

5 (27.8)

Red spots ? angiodysplasias

1 (5.6)

Varices

2 (11.1)

Varices ? angiodysplasias

3 (16.7)

Angiodysplasias ? active

1 (5.6)

bleeding

2 (11.1)

Non-PHE (n = 27) Varices ? active bleeding

2 (7.4)

Vascular lesion

6 (22.2)

Mucosal lesion

1 (3.7)

Mucosal lesion ? active bleeding 1 (3.7)

Tumor

5 (18.5)

Other

12 (44.4)

No specic nding
PHE portal hypertensive enteropathy

underwent CE to evaluate protein-losing enteropathy.

The
overall diagnostic yield was 71.1 % (32/45). The CE
results are summarized in Table 2.

Discussion
PH-related disease can be a cause of bleeding in cirrhosis
patients [2]. Unlike PHG and PHC, data on PHE are scarce
due to the relative inaccessibility of the small bowel [14].
Although our knowledge of PHE has expanded with the
introduction of CE and DBE into clinical practice, the true
prevalence of PHE and related clinical factors remain
unclear. To date, there has been no multicenter study based
on the Capsule Endoscopy Nationwide Database Registry.
Therefore, we evaluated the prevalence and clinical signicance of PHE using CE in cirrhosis patients with PH.
According to data derived from a few small studies, the
prevalence of PHE in cirrhosis patients exceeds 60 % [1,
57]. In our study, the prevalence of PHE was 40 %, which
was lower than reported previously. However, when
applying the narrow denition of PHE dened as edematous and hyperemic lesions that are reminiscent of
inammatory lesions [8], the prevalence of PHE was 18 %,
which is lower than our result. Overestimation and different interpretations might explain this.

123
1040

Dig Dis Sci (2014) 59:10361041

Fig. 1 Capsule endoscopy ndings in patients with portal

hypertensive enteropathy. a Hyperemic mucosal change. b Herring roe
appearance (edematous, swollen, and rounded villi). c Mucosal

Table 4 Univariate and multivariate analysis of the portal

hyper-

granularity with edema. d Red spots (arrow). e Angiodysplasia

(arrow). f Varix with bluish discoloration (arrow). g Saccular varix
with a bluish color change. h Active variceal bleeding in the jejunum

Table 5 Treatment and clinical outcomes

tensive enteropathy and non-portal hypertensive enteropathy
groups
Variable
Univariate
Multivariate
p

OR

95 % CI

Bleeding history
No
0.745
Yes
CTP score
Child A/B

0.002

Child C

0.81innity

0.136

EV severity
\Grade 2

0.819

CGrade 2
0.175

0.126

Yes
CT score

C3

Treatment
Interventional

0.066

Endoscopic

7 (38.9)
2 (11.1)

4 (14.8)
3 (11.1)

Radiologic

4 (22.2)

0 (0.0)

Surgical

1 (5.6)

1 (3.7)

11 (61.1)

23 (85.2)

Follow up duration
(mean SD; days)

18.6 25.9 24.6 25.3 0.453

Rebleeding after

7 (46.7)

10 (40.0)

Small bowel

5 (71.4)
2 (28.6)

5 (50.0)
5 (50.0)

Extra-small bowel

3 (16.7)

4 (14.8)

0 (0.0)

0 (0.0)

Small bowel bleeding

0 (0.0)

1 (25.0)

Extra-small bowel

3 (100.0)

2 (50.0)

bleeding

0 (0.0)

1 (25.0)

Cause of death

PHC

\3

(n = 18) (%) (n = 27) (%)

Site

Yes
No

Non-PHE

treatmenta

PHG
No

PHE

Conservative

Ref
7.08

Variable

0.749
0.622

0.836

Liver related
0.004a

Otherb
PHE portal hypertensive enteropathy, SD standard deviation

Ref
11.19

1.59innity

0.040

PHE portal hypertensive enteropathy, OR odds ratio, CI

condence
interval, CTP ChildTurcottPugh, EV esophageal varix, PHG
portal
hypertensive gastropathy, PHC portal hypertensive colopathy,
CT
computed tomography
Denote signicant difference (p \ 0.05)

Rebleeding rate among 40 patients who were followed

123

Aspiration pneumonia, respiratory arrest

In the PHE group, the most common nding was mul-

Dig Dis Sci (2014) 59:10361041

tiple angiodysplasias, which is similar to the results of most

previous studies. In our study, varices and active bleeding

1041

were observed during CE in 38.9 and 16.6 % of the

and deciding treatment methods in cirrhosis patients with
patients with PHE, respectively, and were more frequent
than the reported rates of varices (8.121.4 %) and
Acknowledgments We gratefully and sincerely thank Ji Sung Lee,
active
PhD, Biostatistical Consulting Unit, Soonchunhyang University
bleeding (5.511 %) [1, 5, 7, 13]. This suggests that
Medical Center, Seoul, Korea, who helped with the statistical
PHE is
analysis.
the cause of meaningful GI bleeding or anemia in
cirrhosis
patients.
De Palma et al. [1] reported that grade 2 or more EV,
Conict of interest None.
PHG, PHC, and CTP class C cirrhosis were all
signicantly
associated with PHE. In our study, only a high CT score
was signicantly related to PHE in cirrhosis patients
PH underwent CE and were treated at tertiary-care
hospiwith
tals because of the severity of disease and
PH. It is true that CE is useful for detecting PHE. Unfortunately, CE cannot be used routinely for cirrhosis
availability of
CE. Therefore, we believe that the domestic
patients
with PH in Korea because of the cost. Therefore, we prosituation could
posed a new CT scoring system, which could better
minimize the unpredictable selection bias. Fourth,
select
each
nding in our CT scoring system was not validated.
patients who should undergo CE because of the
suspected
Finally, we did not acquire sufcient follow-up data
because of the limitations of the registry.
presence of PHE, especially portal hypertensive patients
p
Nevertheless, we
with OGIB.
believe that this study has value because the
Although argon plasma coagulation, thalidomide, or
prevalence of
transjugular intrahepatic portosystemic shunt
PHE and PHE-related bleeding, and associated
placement
have been reported as treatments [15], no
clinical
recommendations
factors, were identied based on a large database.
In conclusion, the prevalence of PHE was 40 %.
for the management of bleeding due to PHE exist. In
a
our
PHE is
more prevalent in cirrhosis patients with PH who
study, more than 60 % of the patients with PHE were
treated conservatively. Regardless of the type of
have a
therapy,
high CT score. Although additional larger,
however, CE could differentiate conservative treatment
prospective
studies are needed, CE is a useful tool for
from the need for further treatment or intensive care.
CE is
evaluating PHE
important in cirrhosis patients with PH because it
enables
the identication of treatable small bowel lesions, and
can
help to optimize treatment on a case-by-case basis.
We recognize the potential limitations of this study.
First, it included a small number of patients and hadathe a
disadvantage that no control group was included.
b
Second,
this was a retrospective analysis and PH-related
diseases
a
were not well dened, so differences in interpretation
between institutions could exist. Third, patient selection
bias might have existed because the data were
selected
based on a database that included mainly tertiary-care
hospitals. In Korea, however, most cirrhosis patients
with

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