Quick Case: Portal Hypertensive Duodenopathy

By Jay Bapaye, MD (GI Fellow) and Klaus Mönkemüller, MD, PhD, FASGE, FJGES (Professor of Medicine), Virginia Tech Carilion School of Medicine, Virginia, USA

60-year-old male with cirrhosis presented with microcytic anemia and hemoccult positive stools. EGD, colonoscopy and capsule endoscopy were reported as normal. A repeat EGD was performed and portal hypertensive duodenopathy (PHD) was diagnosed both endoscopically and confirmed on histology (Photo)

Portal hypertensive duodenopathy (PHD) is a common condition in patients with cirrhosis and portal hypertension. We have also proposed the name of duodenal antral vascular ectasias (DAVE), as histologically, this condition often mimics GAVE (gastric vascular ectasias).

Importantly, PHD or DAVE is often missed during endoscopy. As you can see from Panel A, which shows a "normal" normal mucosa. However, after using water immersion technique the erythema and edema of the mucosa becomes quite evident. Panel E shows a closer look at the mucosa, with characteristic "snakeskin" pattern. This snakeskin pattern is more evident with NBI (panel F). Patients with PHD or DAVE often have microcytic anemia due to occult or overt gastrointestinal bleeding. Bleeding occurs microscopically from the congested mucosa, but also micro- and macroscopically from tiny angiodysplasias (Panels C, D, G, H). Panel G shows the angiodysplasias using water immersion technique. In Panel H the scope was advanced closer to the mucosa. The angiodysplasias in PHD and DAVE are somewhat different than the classic angiodysplasias occurring in elderly patients or those with Heyde syndrome.

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