Quick Case: Portal Hypertensive Duodenopathy

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.

Ready to elevate your endoscopy practice?

Transform your practice with EndoCollab.

About the authors

Jay Bapaye, MD

Gastroenterology Fellow, PGY-6

Carilion Clinic / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Jay Amol Bapaye, MD, is a senior gastroenterology fellow at Carilion Clinic and Virginia Tech Carilion School of Medicine. He received his medical degree from Smt. Kashibai Navale Medical College and Hospital in Pune, India, and completed his internal medicine residency at Rochester General Hospital. His research interests include advanced endoscopy, peroral endoscopic myotomy, and EUS-guided interventions, with publications in journals including Digestive Endoscopy and Endoscopy.

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

Save this article as a PDF

Drop your email and we'll open a print-ready version you can save as a PDF — and you'll start getting our weekly GI endoscopy newsletter.

← All articles