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Fujishiro M, Iguchi M, Ono S, Funasaka K, Sakata Y, Mikami T, Kataoka M, Shimaoka S, Michida T, Igarashi Y, Tanaka S. Guidelines for endoscopic management of nonvariceal upper gastrointestinal bleeding (second edition). Dig Endosc 2025; 37:447-469. [PMID: 40114631 DOI: 10.1111/den.15019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2024] [Accepted: 02/19/2025] [Indexed: 03/22/2025]
Abstract
The Japan Gastroenterological Endoscopy Society has prepared Guidelines for Endoscopic Practice in Nonvariceal Upper Gastrointestinal Bleeding as part of the initiative to develop evidence-based endoscopic practice guidelines. Hemorrhagic gastroduodenal (peptic) ulcers are the primary cause of nonvariceal upper gastrointestinal bleeding. With the advent of a super-aged society, the cases caused by Helicobacter pylori are on the decline, whereas those caused by drugs (e.g. aspirin) have been increasing. Endoscopic hemostasis is currently the first-line treatment for nonvariceal upper gastrointestinal bleeding, and various methods have been devised for this purpose. It is recommended to stabilize the vital signs of the patient before and after endoscopic hemostasis with appropriate management based on an assessment of the severity of illness, in addition to the administration of acid secretion inhibitors. These guidelines describe the evaluation and initial treatment of nonvariceal upper gastrointestinal bleeding, as well as the selection of endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding and its management after endoscopic hemostasis. This is achieved by classifying nonvariceal upper gastrointestinal bleeding into two main categories, namely, peptic ulcer and other types of gastrointestinal bleeding. We prepared statements for any available literature with supporting evidence, including the levels of evidence and recommendations. New evidence has been pooled since the publication of the first edition in this area; however, the levels of evidence and recommendations mostly remain low.
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Affiliation(s)
| | | | - Satoshi Ono
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kohei Funasaka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Tatsuya Mikami
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Tomoki Michida
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Shinji Tanaka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Gangwani MK, Haghbin H, Hasan F, Dillard J, Jaber F, Dahiya DS, Ali H, Kamal F, Hayat U, Lee-Smith W, Sohail A, Inamdar S, Aziz M, Adler DG. Comparing Endoscopic Treatment Modalities for Gastric Antral Vascular Ectasia: Efficacy, Safety, and Outcomes in a Network Meta-analysis. J Clin Gastroenterol 2024:00004836-990000000-00349. [PMID: 39312519 DOI: 10.1097/mcg.0000000000002057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 07/15/2024] [Indexed: 09/25/2024]
Abstract
OBJECTIVE Gastric antral vascular ectasia (GAVE) is characterized by vascular ectasias accounting for 4% of nonvariceal upper gastrointestinal bleeds, which can range from occult bleeds to severe acute upper gastrointestinal bleeding. In turn, GAVE can lead to severe morbidity and recurrent hospitalization. Current endoscopic treatments for GAVE include argon plasma coagulation (APC), endoscopic band ligation (EBL), and radiofrequency ablation. With this significant burden in mind, a systematic review and network meta-analysis were conducted to compare the efficacy and safety of various modalities in the treatment of GAVE. METHODS All studies that involved adults and children with endoscopic characteristics of GAVE undergoing treatment with APC, EBL, radiofrequency ablation, or a combination of 2 treatment modalities were included. RESULTS There was no statistical difference in the rate of adverse events and the number of red blood cell transfusions across all 3 groups (APC, EBL, and APC + EBL). However, statistical differences were noted for outcomes of bleeding recurrence, length of hospitalization, and change in hemoglobin status. EBL exhibited a significant decrease in bleeding recurrence when compared with APC. Moreover, shorter hospitalization stays were seen in APC + EBL and EBL groups compared with APC, and a beneficial change in hemoglobin status was also more often seen in APC + EBL and EBL groups compared with APC. CONCLUSIONS Based on this study, EBL was found to have superior efficacy when compared with APC for the treatment of GAVE; however, there was no significant difference in rates of adverse events between APC, EBL, and combination therapy.
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Affiliation(s)
- Manesh Kumar Gangwani
- Department of Gastroenterology and Hepatology, University of Arkansas Medical Sciences, Little Rock, AR
| | - Hossein Haghbin
- Department of Gastroenterology and Hepatology, Ascension Providence Hospital, Southfield, MI
| | - Fariha Hasan
- Department of Internal Medicine, Cooper University Hospital, Camden, NJ
| | - Julia Dillard
- Department of Medicine, University of Toledo Medical Center
| | - Fouad Jaber
- Department of Internal Medicine, University of Missouri-Kansas City
| | - Dushyant Singh Dahiya
- Department of Gastroenterology and Hepatology, School of Medicine, University of Kansas, Kansas City, MO
| | - Hassam Ali
- Department of Gastroenterology and Hepatology, East Carolina University Health, Greenville, NC
| | - Faisal Kamal
- Department of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia
| | - Umar Hayat
- Department of Internal Medicine, Geisinger Health, Wilkes-Barre, PA
| | | | - Amir Sohail
- Department of General Surgery, New York University Langone Health, Long Island, NY
| | - Sumant Inamdar
- Department of Gastroenterology and Hepatology, University of Arkansas Medical Sciences, Little Rock, AR
| | - Muhammad Aziz
- Department of Medicine, University of Toledo Medical Center
- Department of Gastroenterology and Hepatology, Bon Secours Mercy Hospital, Toledo, OH
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy, Gastroenterology, and Hepatology, Porter Adventist Hospital, Centura Health, Denver, CO
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Khalifa A, Rockey DC. Role of Endoscopy in the Diagnosis, Grading, and Treatment of Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia. Gastrointest Endosc Clin N Am 2024; 34:263-274. [PMID: 38395483 DOI: 10.1016/j.giec.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are 2 distinct gastric vascular abnormalities that may present with acute or chronic blood loss. PHG requires the presence of portal hypertension and is typically associated with chronic liver disease, whereas there is controversy about the association of GAVE with chronic liver disease and/or portal hypertension. Distinguishing between GAVE and PHG is crucial because their treatment strategies differ. This review highlights characteristic endoscopic appearances and the clinical features of PHG and GAVE, which, in turn, aid in their appropriate management.
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Affiliation(s)
- Ali Khalifa
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA.
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Desai PN, Patel CN, Kabrawala M, Nanadwani S, Mehta R, Prajapati R, Patel N, Sethia M. Distal Endoscopic Attachments. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1755336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
AbstractEndoscopy is an evolving science and the last two decades has seen it expand exponentially at a pace unapparelled in the past. With the advancement in new procedures like image-enhanced endoscopy, magnifying endoscopy, third space endoscopy, and highly advanced endoscopic ultrasound procedures, endoscopic accessories are also evolving to cater the unmet needs. Endoscopic cap or distal attachment cap is a simple but very important accessory in the endoscopists' armamentarium which has changed the path of endoscopic procedures. It has so far been used commonly mostly for variceal ligation and endoscopic mucosal resections for colorectal polyps. But the horizon of its use has expanded in the recent years for difficult clinical scenarios like providing stability to the endoscope, overcoming blind spots during screening colonoscopies, maintaining clear field of vision during endotherapy of gastrointestinal bleeding, and during magnification endoscopy for lesion characterizations and so on. These caps are of different shapes, sizes, colors, and material depending on manufacturers and their implications while performing varied endoscopies. This review summarizes the clinical utilities of the cap in diagnostic as well as therapeutic endoscopy and its expanding indications of use.
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Affiliation(s)
- Pankaj N. Desai
- Department of Endoscopy and Endosonography, SIDS Hospital & Research Centre, Surat, Gujarat, India
| | - Chintan N. Patel
- Department of Endoscopy and Endosonography, SIDS Hospital & Research Centre, Surat, Gujarat, India
| | - Mayank Kabrawala
- Department of Gastroenterology, SIDS Hospital & Research Centre, Surat, Gujarat, India
| | - Subhash Nanadwani
- Department of Gastroenterology, SIDS Hospital & Research Centre, Surat, Gujarat, India
| | - Rajiv Mehta
- Department of Gastroenterology, SIDS Hospital & Research Centre, Surat, Gujarat, India
| | - Ritesh Prajapati
- Department of Gastroenterology, SIDS Hospital & Research Centre, Surat, Gujarat, India
| | - Nisharg Patel
- Department of Gastroenterology, SIDS Hospital & Research Centre, Surat, Gujarat, India
| | - Mohit Sethia
- Department of Gastroenterology, SIDS Hospital & Research Centre, Surat, Gujarat, India
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Fortuna L, Bottari A, Bisogni D, Coratti F, Giudici F, Orlandini B, Dragoni G, Cianchi F, Staderini F. Gastric Antral Vascular Ectasia (GAVE) a case report, review of the literature and update of techniques. Int J Surg Case Rep 2022; 98:107474. [PMID: 35963152 PMCID: PMC9386635 DOI: 10.1016/j.ijscr.2022.107474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 07/30/2022] [Accepted: 07/30/2022] [Indexed: 01/10/2023] Open
Abstract
Introduction and importance Gastric Antral Vascular Ectasia is a rare disorder that causes up to 4 % of severe acute gastrointestinal bleeding. It affects elderly females with iron deficiency anemia due to chronic blood loss as a common presenting sign. Case presentation We report the case of a 70-year-old man admitted to the Urgency Department for severe asthenia associated with abdominal pain and severe anemia. An urgent upper endoscopic examination showed antral hyperemic streaks and vascular ectasias extending from the pyloric ring to the gastric body as well as signs of recent bleeding. Histological results demonstrated the pathognomonic features of GAVE. Clinical discussion The first line treatment is considered argon plasma coagulation (APC), given its wider availability, safety, efficacy and cost-effectiveness. In current literature, other therapies and different types of endoscopic treatments have been proposed, such as EBL, RFA and Yag: laser. To date, there is no specific recommendation that privileges one method over another in the treatment of GAVE, although APC has proven effective and even better in terms of complications and costs than the other techniques. Conclusion In our experience, endoscopic coagulation with APC probes is a relatively easy-to-use technique with low cost, minimal invasiveness and provides immediate results. On the other hand, a standardized algorithm is also required concerning to the different subtypes to give the best treatment in every case.
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Hirsch BS, Ribeiro IB, Funari MP, Sagae VMT, Mancini FC, Oliveira GHPD, Moura EGHD, Bernardo WM. Endoscopic treatment of gastric antral vascular ectasia. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2022; 68:125-134. [PMID: 35239866 DOI: 10.1590/1806-9282.2022d682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 05/21/2025]
Affiliation(s)
- Bruno Salomão Hirsch
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina da, Gastrointestinal Endoscopy Unit - São Paulo, Brazil
| | - Igor Braga Ribeiro
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina da, Gastrointestinal Endoscopy Unit - São Paulo, Brazil
| | - Mateus Pereira Funari
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina da, Gastrointestinal Endoscopy Unit - São Paulo, Brazil
| | - Vitor Massaro Takamatsu Sagae
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina da, Gastrointestinal Endoscopy Unit - São Paulo, Brazil
| | - Fabio Catache Mancini
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina da, Gastrointestinal Endoscopy Unit - São Paulo, Brazil
| | | | | | - Wanderley Marques Bernardo
- Universidade de São Paulo, Hospital das Clínicas da Faculdade de Medicina da, Gastrointestinal Endoscopy Unit - São Paulo, Brazil
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Abdo M, Moustafa A, Mostafa I, Abdelbary MS, Elatar G, Rahim AA, Abdelhamid M, Abdelhalim H. To coagulate, ligate, or both: a randomized study comparing the safety and efficacy of two endoscopic approaches for managing gastric antral vascular ectasia in cirrhotic patients. EGYPTIAN LIVER JOURNAL 2022. [DOI: 10.1186/s43066-022-00173-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Gastric antral vascular ectasia (GAVE) is an uncommon but important cause of gastrointestinal bleeding in cirrhotic patients. Argon plasma coagulation (APC) is the standard therapy for GAVE. Endoscopic band ligation (EBL) is an emerging, safe and effective treatment for GAVE. The best way of applying EBL in the management of GAVE is not clear yet.
Aim
We aimed to determine the safety and efficacy of APC alternating with EBL versus EBL alone for managing GAVE in cirrhotic patients.
Patients and methods
Forty cirrhotic patients with bleeding GAVE were randomized to receive either APC alternating with EBL (20 patients) or EBL alone (20 patients) until GAVE lesions are eradicated. Gastroscopy was done 6 months after eradication of GAVE lesions to document recurrence. Cessation of bleeding, rise of hemoglobin level, need for transfusion, hospitalization, complications, number of sessions, and recurrence of GAVE in both groups were statistically analyzed.
Results
Patients in both groups showed significantly high rate of bleeding cessation, improvement in hemoglobin levels, reduction in transfusions, and hospitalizations. There was no statistically significant difference regarding the recurrence of GAVE between the two groups. There were no complications seen in the combined therapy group. Twenty percent of the patients in the EBL group had complications including hypertrophied polyp formation and post-band ulcerations.
Conclusion
APC alternating with EBL and EBL alone are effective methods in the treatment of bleeding GAVE. Combined therapy has the potential to decrease the number of banding sessions and the number of rubber bands required to treat GAVE, consequently decreasing the incidence of band-related complications.
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Mohan BP, Toy G, Kassab LL, Ponnada S, Chandan S, Parbhu S, Chandna S, Adler DG. Endoscopic band ligation in the treatment of gastric antral vascular ectasia: a systematic review and meta-analysis. Gastrointest Endosc 2021; 94:1021-1029.e10. [PMID: 34480922 DOI: 10.1016/j.gie.2021.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/14/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Gastric antral vascular ectasia (GAVE) is typically treated by endoscopic thermal therapies. Endoscopic band ligation (EBL) has been reported in the treatment of GAVE with encouraging results. However, EBL is not widely used to this end. METHODS We conducted a comprehensive search of several databases (inception to May 2021) to identify studies reporting on the use of EBL in the treatment of GAVE. A random-effects model was used to calculate the pooled rates; I2 values and 95% prediction intervals were calculated to assess the heterogeneity. RESULTS Ten studies (194 patients) were included in the final analysis. The pooled rate of treatment responders with EBL in GAVE was 81% (95% confidence interval [CI], 62.2-91.7), and GAVE recurrence was 15.4% (95% CI, 4.5-41.3). The pooled mean number of treatment sessions required was 2.4 (95% CI, 2.2-2.7), and the number of bands used to achieve eradication per patient was 15.1 (95% CI, 10.7-19.4). The pooled mean difference of pre- to post-treatment hemoglobin was 1.5 (95% CI, .9-2.2; P = .001), pre- to post-treatment units of packed red blood cells transfused was 1.1 (95% CI, .4-1.9; P = .002), and pre- to post-treatment hospital length of stay was .5 days (95% CI, .1-.9; P = .01). The pooled rate of overall adverse events was 15.9% (95% CI, 10.4-23.7). CONCLUSIONS EBL demonstrated excellent clinical outcomes in the treatment of GAVE with minimal adverse events. Multicenter randomized controlled trials comparing EBL and other modalities as initial therapy are warranted.
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Affiliation(s)
- Babu P Mohan
- Department of Gastroenterology & Hepatology, University of Utah Health School of Medicine, Salt Lake City, Utah, USA
| | - Gregory Toy
- Department of Internal Medicine, University of Utah Health School of Medicine, Salt Lake City, Utah, USA
| | - Lena L Kassab
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh Ponnada
- Department of Internal Medicine, Carilion Roanoke Medical Center, Roanoke, Virginia, USA
| | - Saurabh Chandan
- CHI Creighton University Medical Center, Omaha, Nebraska, USA
| | - Sheeva Parbhu
- Department of Gastroenterology & Hepatology, University of Utah Health School of Medicine, Salt Lake City, Utah, USA
| | - Shaun Chandna
- Department of Hepatology & Liver Transplant, University of Utah Health School of Medicine, Salt Lake City, Utah, USA
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy, Centura Health, Denver, Colorado, USA
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Hirsch BS, Ribeiro IB, Funari MP, de Moura DTH, Matuguma SE, Sánchez-Luna SA, Mancini FC, de Oliveira GHP, Bernardo WM, de Moura EGH. Endoscopic Band Ligation Versus Argon Plasma Coagulation in the Treatment of Gastric Antral Vascular Ectasia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Endosc 2021; 54:669-677. [PMID: 34053215 PMCID: PMC8505186 DOI: 10.5946/ce.2021.063] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/27/2021] [Accepted: 03/28/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND/AIMS Argon plasma coagulation (APC) is the most commonly used endoscopic treatment for gastric antral vascular ectasia (GAVE). Endoscopic band ligation (EBL) has emerged as an alternative therapy. Our goal was to evaluate the feasibility, efficacy, and safety of APC and EBL for the treatment of GAVE. This is the first systematic review that included only randomized controlled trials (RCTs) on this topic. METHODS A comprehensive search was performed using electronic databases to identify RCTs comparing APC and EBL for the treatment of GAVE following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS Four RCTs were included, with a total of 204 patients. EBL was related to higher endoscopic eradication rates risk difference [RD], 0.29; 95% confidence interval [CI] [0.14, 0.44]; I2=0%) and less bleeding recurrence than APC (RD, 0.29; 95% CI [0.15, 0.44]; I2=0%). Patients treated with EBL required fewer blood transfusions (mean difference [MD], 1.49; 95% CI [0.28, 2.71]; I2=96%) and hospitalizations (MD, 0.29; 95% CI [0.19, 0.39]; I2=0%). The number of sessions required for the obliteration of lesions was higher with APC. There was no difference in the incidence of adverse events. CONCLUSION EBL is superior to APC in the treatment of GAVE in terms of endoscopic eradication rates, recurrence of bleeding, and transfusion requirements.
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Affiliation(s)
- Bruno Salomão Hirsch
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Mateus Pereira Funari
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | | | - Sergio Eiji Matuguma
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Sergio A. Sánchez-Luna
- Center for Advanced Endoscopy, Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Department of Internal Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Fabio Catache Mancini
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | | | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
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Peng M, Guo X, Yi F, Shao X, Wang L, Wu Y, Wang C, Zhu M, Bian O, Ibrahim M, Chawla S, Qi X. Endoscopic treatment for gastric antral vascular ectasia. Ther Adv Chronic Dis 2021; 12:20406223211039696. [PMID: 34408826 PMCID: PMC8366108 DOI: 10.1177/20406223211039696] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/22/2021] [Indexed: 02/05/2023] Open
Abstract
Gastric antral vascular ectasia (GAVE) is one of the uncommon causes of upper gastrointestinal bleeding. Major treatment of GAVE includes pharmacotherapy, endoscopy, and surgery. The efficacy and safety of pharmacotherapy have not been sufficiently confirmed; and surgery is just considered when conservative treatment is ineffective. By comparison, endoscopy is a common treatment option for GAVE. This paper reviews the currently used endoscopic approaches for GAVE, mainly including argon plasma coagulation (APC), radiofrequency ablation (RFA), and endoscopic band ligation (EBL). It also summarizes their efficacy and procedure-related adverse events. The endoscopic success rate of APC is 40-100%; however, APC needs several treatment sessions, with a high recurrence rate of 10-78.9%. The endoscopic success rates of RFA and EBL are 90-100% and 77.8-100%, respectively; and their recurrence rates are 21.4-33.3% and 8.3-48.1%, respectively. Hyperplastic gastric polyps and sepsis are major adverse events of APC and RFA; and Mallory-Weiss syndrome is occasionally observed after APC. Adverse events of EBL are rare and mild, such as nausea, vomiting, esophageal or abdominal pain, and hyperplastic polyps. APC is often considered as the first-line choice of endoscopic treatment for GAVE. RFA and EBL have been increasingly used as alternatives in patients with refractory GAVE. A high recurrence of GAVE after endoscopic treatment should be fully recognized and cautiously managed by follow-up endoscopy. In future, a head-to-head comparison of different endoscopic approaches for GAVE is warranted.
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Affiliation(s)
- Mengyuan Peng
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
- Postgraduate College, Jinzhou Medical University, Jinzhou, P.R. China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Fangfang Yi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Xiaodong Shao
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Yanyan Wu
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Chunmei Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Menghua Zhu
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Ou Bian
- Department of No.1 Cadre Ward, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Saurabh Chawla
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, Liaoning Province 110840, China
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McCarty TR, Hathorn KE, Chan WW, Jajoo K. Endoscopic band ligation in the treatment of gastric antral vascular ectasia: a systematic review and meta-analysis. Endosc Int Open 2021; 9:E1145-E1157. [PMID: 34222641 PMCID: PMC8216786 DOI: 10.1055/a-1401-9880] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/15/2021] [Indexed: 01/10/2023] Open
Abstract
Background and study aims While argon plasma coagulation (APC) is the first-line treatment for gastric antral vascular ectasia (GAVE), endoscopic band ligation (EBL) has shown promising results. The aim of this study was to perform a systematic review and meta-analysis to evaluate the effectiveness of EBL for the treatment of GAVE. Methods Individualized search strategies were developed in accordance with PRISMA and MOOSE guidelines through September 1, 2020. Measured outcomes included endoscopic success (defined as GAVE eradication/improvement), change in hemoglobin, transfusion dependency, number of treatment sessions, adverse events, rebleeding, and bleeding-associated mortality. Outcomes were compared among studies evaluating EBL versus APC. Results Eleven studies (n = 393; 59.39 % female; mean age 58.65 ± 8.85 years) were included. Endoscopic success was achieved in 87.84 % [(95 % CI, 80.25 to 92.78); I 2 = 11.96 %] with a mean number of 2.50 ± 0.49 treatment sessions and average of 12.40 ± 3.82 bands applied. For 8 studies comparing EBL (n = 143) versus APC (n = 174), there was no difference in baseline patient characteristics. However, endoscopic success was significantly higher for EBL [OR 6.04 (95 % CI 1.97 to 18.56; P = 0.002], requiring fewer treatment sessions (2.56 ± 0.81 versus 3.78 ± 1.17; P < 0.001). EBL was also associated with a greater increase in post-procedure hemoglobin [mean difference 0.35 (95 % CI 0.07 to 0.62; P = 0.0140], greater reduction in transfusions required [mean difference -1.46 (95 % CI -2.80 to -0.12; P = 0.033], and fewer rebleeding events [OR 0.11 (95 % CI, 0.04 to 0.36); P < 0.001]. There was no difference in adverse events or bleeding-associated mortality ( P > 0.050). Conclusions EBL appears to be safe and effective for treatment of GAVE, with improved outcomes when compared to APC.
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Affiliation(s)
- Thomas R. McCarty
- Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
| | - Kelly E. Hathorn
- Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
| | - Walter W. Chan
- Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
| | - Kunal Jajoo
- Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
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Chalhoub JM, Umar J, Groudan K, Hamadeh N, Desilets DJ, Greeff Y. Endoscopic band ligation compared to thermal therapy for gastric antral vascular ectasia: A systematic review and meta-analysis. United European Gastroenterol J 2021; 9:150-158. [PMID: 33210983 PMCID: PMC8259375 DOI: 10.1177/2050640620975243] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 10/17/2021] [Indexed: 12/14/2022] Open
Abstract
Background Gastric antral vascular ectasia is an infrequent cause of gastrointestinal‐related blood loss manifesting as iron‐deficiency anemia or overt gastrointestinal bleeding, and is associated with increased healthcare burdens. Endoscopic therapy of gastric antral vascular ectasia most commonly involves endoscopic thermal therapy. Endoscopic band ligation has been studied as an alternative therapy with promising results in gastric antral vascular ectasia. Aims The primary aim was to compare the efficacy of endoscopic band ligation and endoscopic thermal therapy by argon plasma coagulation for the management of bleeding gastric antral vascular ectasia in terms of the mean post‐procedural transfusion requirements and the mean hemoglobin level change. Secondary outcomes included a comparison of the number of sessions needed for cessation of bleeding, the change in transfusion requirements, and the adverse events rate. Methods PubMed, Medline, SCOPUS, Google Scholar, and the Cochrane Controlled Trials Register were reviewed. Randomized controlled clinical trials and retrospective studies comparing endoscopic band ligation and endoscopic thermal therapy in bleeding gastric antral vascular ectasia, with a follow‐up period of at least 6 months, were included. Statistical analysis was done using Review Manager. Results Our search yielded 516 papers. After removing duplicates and studies not fitting the criteria of selection, five studies including 207 patients were selected for analysis. Over a follow‐up period of at least 6 months, patients treated with endoscopic band ligation had significantly lower post‐procedural transfusion requirements (MD −2.10; 95% confidence interval (−2.42 to −1.77)) and a significantly higher change in the mean hemoglobin with endoscopic band ligation versus endoscopic thermal therapy (MD 0.92; 95% confidence interval [0.39–1.45]). Endoscopic band ligation led to a fewer number of required sessions (MD −1.15; 95% confidence interval [−2.30 to −0.01]) and a more pronounced change in transfusion requirements (MD −3.26; 95% confidence interval [−4.84 to −1.68]). There was no difference in adverse events. Conclusion Results should be interpreted cautiously due to the limited literature concerning the management of gastric antral vascular ectasia. Compared to endoscopic thermal therapy, endoscopic band ligation for the management of bleeding gastric antral vascular ectasia led to significantly lower transfusion requirements, showed a trend toward more remarkable post‐procedural hemoglobin elevation, and a fewer number of procedures. Endoscopic band ligation may improve outcomes and lead to decreased healthcare burden and costs.
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Affiliation(s)
- Jean M Chalhoub
- Division of Gastroenterology and Hepatology, University of Massachusetts, Springfield, Illinois, USA
| | - Jalaluddin Umar
- Division of Gastroenterology and Hepatology, University of Massachusetts, Springfield, Illinois, USA
| | - Kevin Groudan
- Division of Gastroenterology and Hepatology, University of Massachusetts, Springfield, Illinois, USA
| | - Nour Hamadeh
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - David J Desilets
- Division of Gastroenterology and Hepatology, University of Massachusetts, Springfield, Illinois, USA
| | - Yesenia Greeff
- Division of Gastroenterology and Hepatology, University of Massachusetts, Springfield, Illinois, USA
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O'Morain NR, O'Donovan H, Conlon C, Shannon E, Manning D, Slattery E. Is Endoscopic Band Ligation a Superior Treatment Modality for Gastric Antral Vascular Ectasia Compared to Argon Plasma Coagulation? Clin Endosc 2021; 54:548-554. [PMID: 33435659 PMCID: PMC8357586 DOI: 10.5946/ce.2020.236] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/13/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Gastric antral vascular ectasia (GAVE) is a rare acquired vascular lesion of the gastric antrum. The most frequent presentation of GAVE is iron deficiency anemia. Endoscopic therapy is the mainstay of treatment. However, there is no consensus regarding the optimal treatment modality. METHODS A retrospective cohort study was performed on patients with GAVE, including patients receiving endoscopic therapy. Treatment was with either argon plasma coagulation (APC) or endoscopic band ligation (EBL). Basic demographic data, indication for index procedure, number of sessions, and pre- and post-hemoglobin levels were collected. The aim of the study was to compare outcomes across the two treatment modalities. RESULTS One hundred and seventeen diagnoses of GAVE were made. Sixty-two patients (53%) required endoscopic treatment for symptomatic GAVE (female, n=38, 61%; mean age of 74.4 years). Two hundred and eighteen procedures were performed during the study period. APC was performed (n=161, 74%) more frequently than EBL (n=57, 26%). Patients treated with APC at index required a median 5 subsequent therapeutic interventions (APC or EBL), while those treated with EBL at index required a further 2.9 treatments (EBL only) (p<0.05). CONCLUSION APC was the most common treatment modality employed. We demonstrate an increasing incidence of EBL. Patients treated with EBL at index treatment required fewer subsequent treatment sessions and had a greater mean rise in hemoglobin. This suggests a more effective endoscopic response with EBL.
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Affiliation(s)
| | - Helen O'Donovan
- Department of Gastroenterology, University Hospital Galway, Galway, Ireland
| | - Caroline Conlon
- Department of Gastroenterology, University Hospital Galway, Galway, Ireland
| | - Eileen Shannon
- Department of Gastroenterology, University Hospital Galway, Galway, Ireland
| | - Diarmuid Manning
- Department of Gastroenterology, University Hospital Galway, Galway, Ireland
| | - Eoin Slattery
- Department of Gastroenterology, University Hospital Galway, Galway, Ireland
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Piester T, Liu QY. Gastritis, Gastropathy, and Ulcer Disease. PEDIATRIC GASTROINTESTINAL AND LIVER DISEASE 2021:262-274.e7. [DOI: 10.1016/b978-0-323-67293-1.00026-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
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15
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Fábián A, Bor R, Szabó E, Kardos V, Bálint A, Farkas K, Milassin Á, Rutka M, Szántó K, Molnár T, Szűcs M, Lőrinczy K, Orbán-Szilágyi Á, Gyökeres T, Gyimesi G, Szepes A, Kovács V, Rácz I, Szepes Z. Endoscopic treatment of gastric antral vascular ectasia in real-life settings: Argon plasma coagulation or endoscopic band ligation? J Dig Dis 2021; 22:23-30. [PMID: 33128340 DOI: 10.1111/1751-2980.12958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 09/15/2020] [Accepted: 10/27/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The efficacy of argon plasma coagulation (APC) on gastric antral vascular ectasia (GAVE) may be impaired over time and depends greatly on the application settings. Endoscopic band ligation (EBL) may be an alternative, but study on its efficacy is limited. This study aimed to evaluate and compare the clinical efficacy of APC and EBL in treating GAVE. METHODS Changes in the need for blood transfusion, number of treatment sessions and hospitalizations were retrospectively assessed in 63 transfusion-dependent patients with GAVE (mean age: 67.1 y, 54.0% female) treated with either APC or EBL (45 and 18 patients, respectively) in four tertiary endoscopic centers. RESULTS Both methods substantially increased hemoglobin levels and decreased patients' need for a transfusion (22.0 ± 4.0 g/L and -5.62 ± 2.30 units of packed red blood cells [RBC] with APC, and 27.4 ± 6.1 g/L and -4.79 ± 2.46 units of packed RBC with EBL), without a significant statistical difference between the methods. However, fewer EBL sessions were required both for the cessation of need for a transfusion compared with those for the resolution of GAVE lesions (0.90 ± 0.10 vs 1.69 ± 0.31, P = 0.028). CONCLUSIONS Both APC and EBL are effective in GAVE treatment. EBL may be superior in terms of number of treatment sessions, but not in its influence on hemoglobin level and need for transfusion. Further prospective studies with large, homogeneous sample size and standardized APC settings are needed.
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Affiliation(s)
- Anna Fábián
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Renáta Bor
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Ella Szabó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Viktor Kardos
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Anita Bálint
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Klaudia Farkas
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Ágnes Milassin
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Mariann Rutka
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Kata Szántó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Tamás Molnár
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Mónika Szűcs
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Katalin Lőrinczy
- Department of Gastroenterology, Medical Centre, Hungarian Defence Forces, Budapest, Hungary
| | - Ákos Orbán-Szilágyi
- Department of Gastroenterology, Medical Centre, Hungarian Defence Forces, Budapest, Hungary
| | - Tibor Gyökeres
- Department of Gastroenterology, Medical Centre, Hungarian Defence Forces, Budapest, Hungary
| | - György Gyimesi
- Department of Gastroenterology, Bács-Kiskun County University Teaching Hospital, Kecskemét, Hungary
| | - Attila Szepes
- Department of Gastroenterology, Bács-Kiskun County University Teaching Hospital, Kecskemét, Hungary
| | - Valéria Kovács
- Internal Medicine Department and Gastroenterology, Petz Aladár County Teaching Hospital, Győr, Hungary
| | - István Rácz
- Internal Medicine Department and Gastroenterology, Petz Aladár County Teaching Hospital, Győr, Hungary
| | - Zoltán Szepes
- First Department of Medicine, University of Szeged, Szeged, Hungary
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Gastric vascular abnormalities: diagnosis and management. Curr Opin Gastroenterol 2020; 36:538-546. [PMID: 32925176 DOI: 10.1097/mog.0000000000000675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Gastric vascular abnormalities are a well known cause of gastrointestinal bleeding. Due to their recurrent bleeding tendency and potential to cause life-threatening blood loss, gastric vascular abnormalities can result in significant morbidity and cost. RECENT FINDINGS There have been novel advances in medical and endoscopic management of gastric vascular lesions. New data suggest that endoscopic band ligation and ablation may be comparable, or even superior, to argon plasma coagulation (APC) for management of gastric antral vascular ectasia (GAVE). A creative, highly sensitive and specific computer-assisted tool has been developed to facilitate reading video capsule endoscopies for the detection of angiodysplasias, paving the way for artificial intelligence incorporation in vascular lesions diagnostics. Over-the-scope clipping is a relatively new technology that shows promising results in controlling bleeding from Dieulafoy's lesions. SUMMARY In this article, we will broadly review the management of the most prevalent gastric vascular lesions, focusing on the most recent areas of research.
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Naseer M, Lambert K, Hamed A, Ali E. Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding: A review. World J Gastrointest Endosc 2020; 12:1-16. [PMID: 31942229 PMCID: PMC6939122 DOI: 10.4253/wjge.v12.i1.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 08/28/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal bleeding is defined as the bleeding originating from the esophagus to the ligament of Treitz and further classified into variceal and non-variceal gastrointestinal bleeding. Non-variceal upper gastrointestinal bleeding remains a common clinical problem globally. It is associated with high mortality, morbidity, and cost of the health care system. Despite the continuous improvement of therapeutic endoscopy, the 30-d readmission rate secondary to rebleeding and associated mortality is an ongoing issue. Available Food and Drug Administration approved traditional or conventional therapeutic endoscopic modalities includes epinephrine injection, argon plasma coagulation, heater probe, and placement of through the scope clip, which can be used alone or in combination to decrease the risk of rebleeding. Recently, more attention has been paid to the novel advanced endoscopic devices for primary treatment of the bleeding lesion and as a secondary measure when conventional therapies fail to achieve hemostasis. This review highlights emerging endoscopic modalities used in the management of non-variceal upper gastrointestinal related bleeding such as over-the-scope clip, Coagrasper, hemostatic sprays, radiofrequency ablation, cryotherapy, endoscopic suturing devices, and endoscopic ultrasound-guided angiotherapy. In this review article, we will also discuss the technical aspects of the common procedures, outcomes in terms of safety and efficacy, and their advantages and limitations in the setting of non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Maliha Naseer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Karissa Lambert
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Ahmed Hamed
- Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
| | - Eslam Ali
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, East Carolina University, Greenville, NC 27834, United States
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Pérez Martín B, Rodríguez Martínez E, Baamonde de la Torre I, Suárez Pazos N, Díaz Tie M. Gastric Antral Vascular Ectasia Refractory to Endoscopic Treatment. Cir Esp 2019; 98:416-418. [PMID: 31812265 DOI: 10.1016/j.ciresp.2019.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 10/22/2019] [Accepted: 11/06/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Berta Pérez Martín
- Servicio de Cirugía General y Aparato Digestivo, Hospital Arquitecto Marcide, Ferrol, A Coruña, España.
| | - Elisa Rodríguez Martínez
- Servicio de Cirugía General y Aparato Digestivo, Hospital Arquitecto Marcide, Ferrol, A Coruña, España
| | - Iván Baamonde de la Torre
- Servicio de Cirugía General y Aparato Digestivo, Hospital Arquitecto Marcide, Ferrol, A Coruña, España
| | - Natalia Suárez Pazos
- Servicio de Cirugía General y Aparato Digestivo, Hospital Arquitecto Marcide, Ferrol, A Coruña, España
| | - Manuel Díaz Tie
- Servicio de Cirugía General y Aparato Digestivo, Hospital Arquitecto Marcide, Ferrol, A Coruña, España
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Eccles J, Falk V, Montano-Loza AJ, Zepeda-Gómez S. Long-term follow-up in patients with gastric antral vascular ectasia (GAVE) after treatment with endoscopic band ligation (EBL). Endosc Int Open 2019; 7:E1624-E1629. [PMID: 31788543 PMCID: PMC6877425 DOI: 10.1055/a-0977-2870] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/12/2019] [Indexed: 12/16/2022] Open
Abstract
Background and study aims Gastric antral vascular ectasia (GAVE) is a capillary-type vascular malformation of the gastric antrum, usually diagnosed endoscopically in patients presenting with iron deficiency anemia or gastrointestinal bleeding. While there is established evidence for treatment with thermal modalities, such as argon plasma coagulation (APC) therapy, more recent studies have shown endoscopic band ligation (EBL) to be safe and effective in achieving remission. Our study aimed to evaluate long-term outcomes of patients with GAVE who underwent EBL at our institution. Patients and methods We retrospectively reviewed data from 33 patients with GAVE who underwent esophagogastroduodenoscopy and EBL between September 2012 and July 2017 within our institution, looking primarily at clinical response, recurrence, and blood transfusion requirements. Results Clinical response was achieved in 27 patients (81.8%). Among responders, recurrence-free survival decreased with time from 88 % at 1 year to 44 % at 2 years. Thirteen patients (48.1 %) had recurrence of GAVE at a mean time of 18.2 months (range 4.7 - 51.8). The only predictor of recurrence was greater number of pre-procedure blood transfusions. Conclusion This is the first study to evaluate long-term response and recurrence in patients with GAVE after treatment with EBL and predictors of clinical response after initial endoscopic therapy have been identified. While we were able to demonstrate excellent remission achievement rates in our GAVE patients who had undergone EBL, close clinical follow-up is clearly required as almost 50 % will have recurrence at around 18 months.
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Affiliation(s)
- John Eccles
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Vanessa Falk
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Aldo J. Montano-Loza
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Sergio Zepeda-Gómez
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
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Comparison of Argon Plasma Coagulation and Injection Therapy with Adrenalin and Polidocanol in the Management of Bleeding Angiodysplasia in Upper Gastrointestinal Tract. ACTA ACUST UNITED AC 2019; 39:63-68. [PMID: 30864370 DOI: 10.2478/prilozi-2018-0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The term angiodysplasia (AD) refers to acquired malformation of the blood vessels (communications between veins and capillaries), frequently found within the gastrointestinal mucosa and submucosa. AD of stomach and duodenum are cause of upper gastrointestinal bleeding in 4%-7% of patients. The means of treatment are usually endoscopic, including argon plasma coagulation (APC), electrocoagulation, mechanical hemostasis by clippsing, laser photo-coagulation and injection therapy. AIM To compare the success rate, and adverse events (ulcer lesions, perforations) of APC and injection therapy in the treatment of bleeding angiodysplasia in the upper gastrointestinal tract (GIT). MATERIAL AND METHODS In a prospective study including 50 patients with bleeding angiodysplasia of the upper GIT, 35 patients were treated with APC, and remaining 15 with injection therapy using adrenaline and 1.5% solution of polidocanol. Follow-up period was 6 months. RESULTS A total of 50 patients aged 18 to 64 years, 64% male and 36% female, have been treated during 2 years period. The rate of recurrent bleeding and side effects was significantly higher in the adrenaline group (p <0.01). Blood transfusion was required in 68% during the first hospital admission. Angiodysplasia of the stomach was present in 66%, versus 34% in duodenum. CONCLUSION Endoscopy is "gold standard" for diagnosis and treatment of AD in the gastrointestinal tract. The study unveiled APC as more effective treatment option with lower degree of complications and adverse events in comparison to injection therapy in patients with bleeding AD.
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Ghobrial C, Rabea M, Mohsen N, Eskander A. Gastric antral vascular ectasia in portal hypertensive children: Endoscopic band ligation versus argon plasma coagulation. J Pediatr Surg 2019; 54:1691-1695. [PMID: 30119927 DOI: 10.1016/j.jpedsurg.2018.07.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 06/18/2018] [Accepted: 07/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND/PURPOSE Gastric antral vascular ectasia (GAVE) can cause recurrent bleeding and chronic anemia in children with portal hypertension (PHT). We aimed to evaluate the efficacy of EBL in comparison to argon plasma coagulation (APC) in children with PHT, bleeding from GAVE. METHODS This prospective comparative study included 40 children with PHT who presented with nonvariceal GIT bleeding from GAVE. Patients were divided into 2 groups, each including 20 cases: one group was managed with APC and the other with EBL. Endoscopy was repeated every 3-4 weeks until complete ablation of GAVE. Patients were reevaluated earlier in the event of recurrence of bleeding or in case of severe anemia necessitating blood transfusion. A follow-up endoscopy was done 6 months after the last APC or EBL session. RESULTS The ages ranged between 2 and 16 years. The EBL group required a significantly lower number of sessions for complete obliteration of the lesions (1.85 ± 0.81) as compared to APC group (4.15 ± 1.22), p < 0.05. EBL was superior to APC as regards shorter procedure time (p = 0.001), lower blood transfusion requirement (p < 0.05), less hospitalization (p < 0.05) and significantly lower recurrence rate of GAVE after 6 months of follow up (p = 0.01) CONCLUSIONS: EBL is more effective and time saving when compared to APC in treatment of bleeding from GAVE in children. LEVELS OF EVIDENCE Treatment study, Level II (prospective comparative study).
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Affiliation(s)
- Carolyne Ghobrial
- Departments of Pediatrics, Kasr Alainy School of Medicine, Cairo University.
| | - Mohamed Rabea
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Nabil Mohsen
- Departments of Pediatrics, Kasr Alainy School of Medicine, Cairo University
| | - Ayman Eskander
- Departments of Pediatrics, Kasr Alainy School of Medicine, Cairo University
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Smith E, Davis J, Caldwell S. Gastric Antral Vascular Ectasia Pathogenesis and the Link to the Metabolic Syndrome. Curr Gastroenterol Rep 2018; 20:36. [PMID: 29961911 DOI: 10.1007/s11894-018-0644-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE OF REVIEW Gastric antral vascular ectasia (GAVE) is a well-described source of chronic blood loss. We aim to review the previously hypothesized etiologies of GAVE and focus on recent proposed mechanisms, including metabolic syndrome. We will support these theories with newly discovered clinical associations and possible therapeutic implications. RECENT FINDINGS Historically, GAVE has been associated with connective tissue disease and liver disease. Based on these associations and its histologic appearance, GAVE has presumed to be caused by mechanical- and hormonally mediated injury. Recent findings have been notable for a clinical association with aspects of the metabolic syndrome. Therefore, the pathogenic etiology may be akin to aspects of the metabolic syndrome via microvascular injury and neoangiogenesis. The potential etiologies of GAVE include hypergastrinemia, mechanical injury, and microvascular injury with neovascular proliferation particularly in the metabolic syndrome. Further research is needed to evaluate these proposed mechanisms and potential targets for treatment.
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Affiliation(s)
- Elliot Smith
- Division of Gastroenterology and Hepatology, University of Virginia, JPA and Lee St., PO Box 800708, Charlottesville, VA, 22908-0708, USA
| | - Jessica Davis
- Division of Gastroenterology and Hepatology, University of Virginia, JPA and Lee St., PO Box 800708, Charlottesville, VA, 22908-0708, USA
| | - Stephen Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia, JPA and Lee St., PO Box 800708, Charlottesville, VA, 22908-0708, USA.
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Abstract
Gastric antral vascular ectasia (GAVE) is a rare but an important cause of upper gastrointestinal bleeding (UGIB) and commonly presents as occult bleeding that manifests as iron deficiency anemia (IDA). GAVE is commonly associated with chronic illnesses, most frequently liver cirrhosis and connective tissue diseases. The pathogenesis of GAVE is still obscure, and many hypotheses such as mechanical stress, hormonal factors, and autoimmune factors, have been proposed. Upper gastrointestinal endoscopy has a major role in the diagnosis and treatment of GAVE.
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Hsu WH, Wang YK, Hsieh MS, Kuo FC, Wu MC, Shih HY, Wu IC, Yu FJ, Hu HM, Su YC, Wu DC. Insights into the management of gastric antral vascular ectasia (watermelon stomach). Therap Adv Gastroenterol 2018; 11:1756283X17747471. [PMID: 29399041 PMCID: PMC5788127 DOI: 10.1177/1756283x17747471] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/30/2017] [Indexed: 02/04/2023] Open
Abstract
Gastric antral vascular ectasia (GAVE) is an uncommon but important cause of chronic gastrointestinal bleeding. It is often associated with systemic diseases such as autoimmune diseases, liver cirrhosis, chronic renal insufficiency and cardiovascular disease. The etiology of GAVE has not been fully explored and remains controversial. Diagnosis is mainly based on endoscopic presentation with flat or raised erythematous stripes radiating from the pylorus to the antrum and resembles a watermelon. Clinical presentation may range from iron-deficiency anemia secondary to occult blood loss, melena to hematemesis. In past decades, many therapeutic modalities including medical, endoscopic and surgical intervention have been introduced for GAVE treatment with variable efficacy. Herein, we review the efficacy and safety of these treatment options for GAVE.
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Affiliation(s)
- Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yao-Kuang Wang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
| | - Meng-Shu Hsieh
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Fu-Chen Kuo
- Shool of Medicine, College of Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Meng-Chieh Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Hsiang-Yao Shih
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - I-Chen Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Fang-Jung Yu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Huang-Ming Hu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Chung Su
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Maida M, Camilleri S, Manganaro M, Garufi S, Scarpulla G. Radiofrequency Ablation for Treatment of Refractory Gastric Antral Vascular Ectasia: A Systematic Review of the Literature. Gastroenterol Res Pract 2017; 2017:5609647. [PMID: 28835751 PMCID: PMC5556612 DOI: 10.1155/2017/5609647] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/17/2017] [Accepted: 06/28/2017] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND AND STUDY AIMS GAVE is an uncommon cause of upper nonvariceal bleeding and often manifests itself as occult bleeding with chronic anemia. To date, the standard of care for GAVE is endoscopic treatment with thermoablative techniques. Despite good technical results, approximately two thirds of patients remain dependent on transfusions after the therapy. One of the emerging and more promising endoscopic treatments for GAVE is radiofrequency ablation (RFA). The aim of this study is to perform a systematic review of literature in order to assess current evidence supporting the effectiveness of this technique for treatment of refractory GAVE. MATERIALS AND METHODS Through electronic search, we identified 14 records, and after removal of duplicates and irrelevant studies, we selected 10 studies on radiofrequency ablation of GAVE: 4 prospective open-label single-center studies, 1 retrospective multicentric study, and 5 case reports. RESULTS Among all 72 treated patients reported in literature, 74.3% achieved a clinical response, while nonfatal AEs have been reported in 4.2% of cases. CONCLUSIONS Despite some qualitative limitations, all literature data support effectiveness of RFA for treatment of refractory GAVE. In the future, large prospective controlled trials with adequate follow-up are needed to better assess the effectiveness and safety of this procedure.
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Affiliation(s)
- M. Maida
- Section of Gastroenterology, S. Elia-M. Raimondi Hospital, Caltanissetta, Italy
| | - S. Camilleri
- Section of Gastroenterology, S. Elia-M. Raimondi Hospital, Caltanissetta, Italy
| | - M. Manganaro
- Section of Gastroenterology, S. Elia-M. Raimondi Hospital, Caltanissetta, Italy
| | - S. Garufi
- Section of Gastroenterology, S. Elia-M. Raimondi Hospital, Caltanissetta, Italy
| | - G. Scarpulla
- Section of Gastroenterology, S. Elia-M. Raimondi Hospital, Caltanissetta, Italy
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Qiu H, Mao Y, Zeng J, Wang Y, Zhang J, Huang N, Liu Q, Yang Y, Linghu E, Gu Y. Vascular-targeted photodynamic therapy of gastric antral vascular ectasia (GAVE). JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY. B, BIOLOGY 2017; 166:58-62. [PMID: 27871022 DOI: 10.1016/j.jphotobiol.2016.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 10/25/2016] [Accepted: 10/27/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND STUDY AIM Vascular-targeted photodynamic therapy (V-PDT) has been used for several benign vascular diseases. The aim of this pilot study was to demonstrate the potential benefits of VPDT in the treatment of gastric antral vascular ectasia (GAVE). PATIENTS AND METHODS Data from patients with GAVE (n=5) who underwent endoscopic V-PDT were analyzed retrospectively. Pre- and post-V-PDT clinical and endoscopic features, hemoglobin levels, and transfusion requirement were compared. RESULTS The five GAVE patients received one to four sessions of V-PDT. The hemoglobin levels of all five patients increased steadily following V-PDT. Within 6-48months of follow-up, gastrointestinal bleeding and melena disappeared in all five patients and none of the patients needed a transfusion. Endoscopy examinations showed that the dilated vessels had disappeared without scar formation. No significant side effects or adverse reactions were reported. CONCLUSION This preliminary study indicates the good selectivity, safety, and efficacy of V-PDT in the treatment of patients with GAVE. Larger prospective studies are needed to further confirm the feasibility of using V-PDT to treat patients with GAVE.
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Affiliation(s)
- Haixia Qiu
- Department of Laser Medicine, Chinese PLA General Hospital, China
| | - Yongping Mao
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, China.
| | - Jing Zeng
- Department of Laser Medicine, Chinese PLA General Hospital, China
| | - Ying Wang
- Department of Laser Medicine, Chinese PLA General Hospital, China
| | - Jiaying Zhang
- Department of Laser Medicine, Chinese PLA General Hospital, China
| | - Naiyang Huang
- Department of Laser Medicine, Chinese PLA General Hospital, China
| | - Qingsen Liu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, China
| | - Yunsheng Yang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, China
| | - Enqiang Linghu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, China
| | - Ying Gu
- Department of Laser Medicine, Chinese PLA General Hospital, China.
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Zepeda-Gómez S. Endoscopic Treatment for Gastric Antral Vascular Ectasia: Current Options. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 24:176-182. [PMID: 29255747 DOI: 10.1159/000453271] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/04/2016] [Indexed: 01/10/2023]
Abstract
Gastric antral vascular ectasia (GAVE) is a capillary-type vascular malformation located primarily in the gastric antrum. Patients can present with iron-deficiency anemia, overt gastrointestinal bleeding, or both. Diagnosis and characterization is made at endoscopic examination, and the preferred management of patients with GAVE is endoscopic therapy. Herein, we present a review of the evidence about the efficacy, complications, and outcomes of the most frequently used endoscopic therapies for GAVE.
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Emmanuel A. Current management of the gastrointestinal complications of systemic sclerosis. Nat Rev Gastroenterol Hepatol 2016; 13:461-72. [PMID: 27381075 DOI: 10.1038/nrgastro.2016.99] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systemic sclerosis is a multisystem autoimmune disorder that involves the gastrointestinal tract in more than 90% of patients. This involvement can extend from the mouth to the anus, with the oesophagus and anorectum most frequently affected. Gut complications result in a plethora of presentations that impair oral intake and faecal continence and, consequently, have an adverse effect on patient quality of life, resulting in referral to gastroenterologists. The cornerstones of gastrointestinal symptom management are to optimize symptom relief and monitor for complications, in particular anaemia and malabsorption. Early intervention in patients who develop these complications is critical to minimize disease progression and improve prognosis. In the future, enhanced therapeutic strategies should be developed, based on an ever-improving understanding of the intestinal pathophysiology of systemic sclerosis. This Review describes the most commonly occurring clinical scenarios of gastrointestinal involvement in patients with systemic sclerosis as they present to the gastroenterologist, with recommendations for the suggested assessment protocol and therapy in each situation.
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Affiliation(s)
- Anton Emmanuel
- Gastrointestinal Physiology Unit, University College Hospital, 235 Euston Road, London NW1 2BU, UK
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Elhendawy M, Mosaad S, Alkhalawany W, Abo-Ali L, Enaba M, Elsaka A, Elfert AA. Randomized controlled study of endoscopic band ligation and argon plasma coagulation in the treatment of gastric antral and fundal vascular ectasia. United European Gastroenterol J 2016; 4:423-428. [PMID: 27403309 PMCID: PMC4924441 DOI: 10.1177/2050640615619837] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 11/02/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) is characterized by mucosal and submucosal vascular ectasia causing recurrent hemorrhage and thus, chronic anemia, in patients with cirrhosis. Treatment with argon plasma coagulation (APC) is an effective and safe method, but requires multiple sessions of endoscopic therapy. Endoscopic band ligation (EBL) was found to be a good alternative for APC as a treatment for GAVE, especially in refractory cases. The aim of this prospective randomized controlled study was to evaluate the safety and efficacy of EBL, as compared to APC, in the treatment of GAVE and gastric fundal vascular ectasia (GFVE). PATIENTS AND METHODS A total of 88 cirrhotic patients with GAVE were prospectively randomized to endoscopic treatment with either EBL or APC, every 2 weeks until complete obliteration was accomplished; then they were followed up endoscopically after 6 months, plus they had monthly measurement of hemoglobin levels during that period. RESULTS We describe the presence of mucosal and submucosal lesions in the gastric fundal area that were similar to those found in GAVE in 13 patients (29.5%) of the EBL group and 9 patients (20.5%) of the APC group; we named this GFVE. In these cases, we treated the fundal lesions with the same techniques we had used for treating GAVE, according to the randomization. We found that EBL significantly decreased the number of sessions required for complete obliteration of the lesions (2.98 sessions compared to 3.48 sessions in the APC group (p < 0.05)). Hemoglobin levels increased significantly after obliteration of the lesions in both groups, compared to pretreatment values (p < 0.05), but with no significant difference between the two groups (p > 0.05); however, the EBL group of patients required a significantly smaller number of units of blood transfusion than the APC group of patients (p < 0.05). There were no significant differences in adverse events nor complications between the two groups (p > 0.05). CONCLUSIONS This study described and histologically proved the presence of GFVE occurring comcomitantly with GAVE in cirrhotic patients. We showed that GFVE can be successfully managed by EBL or APC. Our study revealed that EBL is more effective and is comparable in safety to APC, in the treatment of GAVE and GFVE in cirrhotic patients.
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Affiliation(s)
| | - Samah Mosaad
- Department of Tropical Medicine, Tanta University Hospital, Egypt
| | | | - Lobna Abo-Ali
- Department of Tropical Medicine, Tanta University Hospital, Egypt
| | - Mohamed Enaba
- Department of Internal Medicine, Tanta University Hospital, Egypt
| | - Aymen Elsaka
- Department of Pathology, Tanta University Hospital, Egypt
| | - Asem A Elfert
- Department of Tropical Medicine, Tanta University Hospital, Egypt
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Fujishiro M, Iguchi M, Kakushima N, Kato M, Sakata Y, Hoteya S, Kataoka M, Shimaoka S, Yahagi N, Fujimoto K. Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding. Dig Endosc 2016; 28:363-378. [PMID: 26900095 DOI: 10.1111/den.12639] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 01/10/2023]
Abstract
Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research.
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Affiliation(s)
| | | | | | - Motohiko Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Shu Hoteya
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Naohisa Yahagi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Gjeorgjievski M, Cappell MS. Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy. World J Hepatol 2016; 8:231-262. [PMID: 26855694 PMCID: PMC4733466 DOI: 10.4254/wjh.v8.i4.231] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 11/30/2015] [Accepted: 01/16/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy (PHG) based on a systematic literature review. METHODS Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "portal" and "gastropathy"; or "portal" and "hypertensive"; or "congestive" and "gastropathy"; or "congestive" and "gastroenteropathy". The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG. RESULTS PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG. PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepatic-portosystemic-shunt and liver transplantation are highly successful ultimate therapies because they reduce the underlying portal hypertension. CONCLUSION PHG is important to recognize in patients with cirrhotic or non-cirrhotic portal hypertension because it can cause acute or chronic GI bleeding that often requires pharmacologic therapy.
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Affiliation(s)
- Mihajlo Gjeorgjievski
- Mihajlo Gjeorgjievski, Mitchell S Cappell, Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
| | - Mitchell S Cappell
- Mihajlo Gjeorgjievski, Mitchell S Cappell, Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
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Abstract
PURPOSE OF REVIEW Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are two types of upper gastrointestinal bleeding that may present similarly, but are managed very differently. This article reviews the pathogenesis and guidelines in management of both of these conditions with emphasis on recent advances in the field. RECENT FINDINGS Off-label use of Hemospray has been shown in several case series to be useful in managing acute bleeding from PHG. Balloon-occluded retrograde transvenous obliteration presents an alternative approach for this condition. Radiofrequency ablation may be an alternative therapy to argon plasma coagulation in the endoscopic treatment of GAVE, as it consists of fewer sessions and has been shown to decrease gastrointestinal blood loss. SUMMARY The treatment options for PHG and GAVE are constantly evolving and expanding. In this review, we present the latest approaches in the gastroenterologist's arsenal to deal with these conditions.
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Garg H, Gupta S, Anand AC, Broor SL. Portal hypertensive gastropathy and gastric antral vascular ectasia. Indian J Gastroenterol 2015; 34:351-8. [PMID: 26564121 DOI: 10.1007/s12664-015-0605-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 10/17/2015] [Indexed: 02/04/2023]
Abstract
Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are gastric mucosal lesions that mostly present as chronic anemia and rarely cause the acute gastrointestinal hemorrhage. Despite similar clinical manifestations, their pathophysiology and management are entirely different. PHG is seen exclusively in patients with portal hypertension, but GAVE can also be observed in patients with other conditions. Their diagnosis is endoscopic, and although generally each of them has a characteristic endoscopic appearance and distribution, there are cases in which the differential is difficult and must rely on histology. This review focuses on the management of both entities. The mainstay of management of PHG is based on portal-hypotensive pharmacological treatment while GAVE benefits from hormonal therapy, endoscopic Nd:YAG laser, and argon plasma coagulation. More invasive options should be reserved for refractory cases.
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Affiliation(s)
- Hitendra Garg
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India.
| | - Subhash Gupta
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India
| | - A C Anand
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India
| | - S L Broor
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India.,Gastroenterology and Hepatology, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India
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Shah N, Cavanagh Y, Kaswala DH, Shaikh S. Development of hyperplastic polyps following argon plasma coagulation of gastric antral vascular ectasia. J Nat Sci Biol Med 2015; 6:479-82. [PMID: 26283860 PMCID: PMC4518440 DOI: 10.4103/0976-9668.160048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The etiology of gastric antral vascular ectasia (GAVE) syndrome or gastric hyperplastic polyps (HPs) is not fully understood. We report a case of gastric HP arising in a patient treated with argon plasma coagulation (APC) for GAVE syndrome. Despite unclear etiologic progression, this and previously reported cases suggest a temporal relationship between the treatment of GAVE and HP. A 68-year-old male with a history of coronary artery disease, congestive heart failure and diabetes type II who initially presented with symptomatic anemia 2 weeks after starting aspirin and clopidogrel therapy. Diagnostic esophagogastroduodenoscopy (EGD) demonstrated diffuse GAVE. He was treated with 5 APC treatments, at 6-week intervals, over a 30 weeks period. 16 months after the initial APC treatment, an EGD performed secondary to persistent anemia demonstrated innumerable, large, bleeding polyps in the gastric antrum. Biopsy performed at that time confirmed hyperplastic gastric polyps. It has been proposed that HPs are regenerative lesions that arise at sites of severe mucosal injury. Our patient's treatment of GAVE with APC created significant mucosal injury, resulting in HP. Technique and genetic factors may have promoted hyperplastic changes during the regeneration of mucosa, at sites previously treated with APC. This case highlights the potential progression of GAVE to HP in a patient with persistent anemia after APC therapy.
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Affiliation(s)
- Nihar Shah
- Department Gastroenterology, Saint Joseph's Regional Medical Center, NJ, USA ; School of Health and Medical Sciences, Seton Hall University, NJ, USA
| | - Yana Cavanagh
- Department of Internal Medicine, Saint Joseph's Regional Medical Center, NJ, USA ; New York Medical College, NY, USA
| | - Dharmesh H Kaswala
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sohail Shaikh
- Department Gastroenterology, Saint Joseph's Regional Medical Center, NJ, USA ; New York Medical College, NY, USA
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Abstract
Background. Gastric antral vascular ectasia (GAVE) also known as “watermelon stomach” (WS) is an uncommon cause of gastrointestinal (GI) blood loss. It typically presents in middle aged females. We are presenting a case of GAVE at an unusually early age with atypical symptoms. Case. A previously healthy 16 y/o Caucasian female presented to the ER with a one-month history of upper abdominal pain. Physical examination was benign except tenderness in the epigastric region. There were no significant findings on laboratory data. Upper endoscopy showed incidental findings of linear striae in the antrum indicative of GAVE but histology was equivocal. Discussion. GAVE is a poorly understood but treatable entity and an increasingly identifiable cause of chronic iron deficiency anemia or acute or occult upper GI bleeding. The pathophysiology of GAVE remains unclear. It is an endoscopic finding characterized by longitudinal columns of tortuous red ectatic vessels (watermelon stripes), pathognomonic for WS. Treatment options include endoscopic, pharmacologic, and surgical approaches. Failure to recognize GAVE can result in delayed treatment for years. Our patient with GAVE was unusually young and was diagnosed incidentally. Due to lack of anemia on laboratory examination we elected to monitor her clinically for any future development of anemia.
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[Watermelon stomach: Chronic renal failure and/or imatinib?]. Nephrol Ther 2015; 11:496-501. [PMID: 26165799 DOI: 10.1016/j.nephro.2015.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/13/2015] [Indexed: 02/07/2023]
Abstract
Watermelon stomach or gastric antral vascular ectasia (GAVE) syndrome is an uncommon cause of sometimes severe upper gastro-intestinal bleeding. Essentially based on a pathognomonic endoscopic appearance, its diagnosis may be unrecognised because mistaken with portal hypertensive gastropathy, while treatment of these two entities is different. Its etiopathogeny remains still unclear, even if it is frequently associated with different systemic illnesses as hepatic cirrhosis, autoimmune disorders and chronic renal failure. The mechanism inducing these vascular ectasia may be linked with mechanical stress on submucosal vessels due to antropyloric peristaltic motility dysfunction modulated by neurohormonal vasoactive alterations. Because medical therapies are not very satisfactory, among the endoscopic modalities, argon plasma coagulation seems to be actually the first-line treatment because the most effective and safe. However, surgical antrectomy may be sometimes necessary. Recently GAVE syndrome appeared as a new adverse reaction of imatinib mesylate, one of the tyrosine kinase inhibitors used in chronic myeloid leukemia, and we report here the observation of such a pathology in one patient treated at the same time by haemodialysis and by imatinib mesylate for chronic myeloid leukemia.
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Parikh K, Ali MA, Wong RCK. Unusual Causes of Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2015; 25:583-605. [PMID: 26142040 DOI: 10.1016/j.giec.2015.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Upper gastrointestinal (GI) bleeding is an important clinical condition managed routinely by endoscopists. Diagnostic and therapeutic options vary immensely based on the source of bleeding and it is important for the gastroenterologist to be cognizant of both common and uncommon etiologies. The focus of this article is to highlight and discuss unusual sources of upper GI bleeding, with a particular emphasis on both the clinical and endoscopic features to help diagnose and treat these atypical causes of bleeding.
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Affiliation(s)
- Keyur Parikh
- Digestive Health Institute, Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA
| | - Meer Akbar Ali
- Digestive Health Institute, Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA
| | - Richard C K Wong
- Digestive Health Institute, Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA.
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Palmer R, Braden B. New and emerging endoscopic haemostasis techniques. Frontline Gastroenterol 2015; 6:147-152. [PMID: 28839802 PMCID: PMC5369562 DOI: 10.1136/flgastro-2014-100540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 01/02/2015] [Accepted: 01/05/2015] [Indexed: 02/04/2023] Open
Abstract
Endoscopic treatment has been accepted as first-line treatment of upper gastrointestinal bleeding, both for variceal as well as for non-variceal haemorrhage. Dual modality treatment including injection therapy with mechanical or thermal haemostatic techniques has shown superior outcome compared with injection monotherapy in non-variceal bleeding. During recent years, new endoscopic devices have been developed and existing endoscopic techniques have been adapted to facilitate primary control of bleeding or achieve haemostasis in refractory haemorrhage. For mechanical haemostasis, larger, rotatable and repositionable clips have been developed; multiple-preloaded clips are also available now. Over the scope clips allow to ligate larger vessels and can close ulcer defects up to 20 mm. Topical, easily applied substances withdraw fluid from the blood and thereby initiate blood clotting. This can be helpful in diffuse oozing bleeding, for example, from tumour or hypertensive gastropathy and has also shown promising results in variceal and arterial bleeding as bridging before definitive treatment is available. Radiofrequency ablation and multiband ligation have emerged as new tools in the endoscopic management of gastric antral vascular ectasia. In acute refractory variceal bleeding, a covered and removable oesophagus stent can provide tamponade and gain time for transport to an interventional endoscopic centre or for radiological intervention such as TIPS.
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Affiliation(s)
- Rebecca Palmer
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
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Lesiones vasculares gástricas en la cirrosis: gastropatía y ectasia vascular antral. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:97-107. [DOI: 10.1016/j.gastrohep.2014.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/12/2014] [Accepted: 10/27/2014] [Indexed: 02/08/2023]
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40
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Radiofrequency Ablation of Treatment-refractory Gastric Antral Vascular Ectasia (GAVE). Surg Laparosc Endosc Percutan Tech 2015; 25:79-82. [DOI: 10.1097/sle.0000000000000033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Nagaraja V, McMahan ZH, Getzug T, Khanna D. Management of gastrointestinal involvement in scleroderma. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2015; 1:82-105. [PMID: 26005632 DOI: 10.1007/s40674-014-0005-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gastrointestinal tract (GIT) commonly affects patients with systemic sclerosis (SSc). The GI involvement is quite heterogeneous varying from asymptomatic disease to significant dysmotility causing complications like malabsorption, weight loss and severe malnutrition. This review focuses on the management of GI involvement in SSc and has been categorized based on the segment of GIT involved. A brief discussion on the role of patient reported outcome measures in SSc-GI involvement has also been incorporated.
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Affiliation(s)
- Vivek Nagaraja
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | | | - Terri Getzug
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan
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Approach to the management of portal hypertensive gastropathy and gastric antral vascular ectasia. Gastroenterol Clin North Am 2014; 43:835-47. [PMID: 25440929 DOI: 10.1016/j.gtc.2014.08.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Gastric antral vascular ectasia (GAVE) and portal hypertensive gastropathy (PHG) are important causes of chronic gastrointestinal bleeding. These gastric mucosal lesions are mostly diagnosed on upper endoscopy and can be distinguished based on their appearance or location in the stomach. In some situations, especially in patients with liver cirrhosis and portal hypertension, a diffuse pattern and involvement of gastric mucosa are seen with both GAVE and severe PHG. The diagnosis in such cases is hard to determine on visual inspection, and thus, biopsy and histologic evaluation can be used to help differentiate GAVE from PHG.
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43
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Tjwa ETTL, Holster IL, Kuipers EJ. Endoscopic management of nonvariceal, nonulcer upper gastrointestinal bleeding. Gastroenterol Clin North Am 2014; 43:707-19. [PMID: 25440920 DOI: 10.1016/j.gtc.2014.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Upper gastrointestinal bleeding (UGIB) is the most common emergency condition in gastroenterology. Although peptic ulcer and esophagogastric varices are the predominant causes, other conditions account for up to 50% of UGIBs. These conditions, among others, include angiodysplasia, Dieulafoy and Mallory-Weiss lesions, gastric antral vascular ectasia, and Cameron lesions. Upper GI cancer as well as lesions of the biliary tract and pancreas may also result in severe UGIB. This article provides an overview of the endoscopic management of these lesions, including the role of novel therapeutic modalities such as hemostatic powder and over-the-scope-clips.
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Affiliation(s)
- Eric T T L Tjwa
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, PO box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - I Lisanne Holster
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, PO box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, PO box 2040, 3000 CA, Rotterdam, The Netherlands
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Baptista V, Marya N, Singh A, Rupawala A, Gondal B, Cave D. Continuing challenges in the diagnosis and management of obscure gastrointestinal bleeding. World J Gastrointest Pathophysiol 2014; 5:523-533. [PMID: 25400996 PMCID: PMC4231517 DOI: 10.4291/wjgp.v5.i4.523] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/28/2014] [Accepted: 07/17/2014] [Indexed: 02/06/2023] Open
Abstract
The diagnosis and management of obscure gastrointestinal bleeding (OGIB) have changed dramatically since the introduction of video capsule endoscopy (VCE) followed by deep enteroscopy and other imaging technologies in the last decade. Significant advances have been made, yet there remains room for improvement in our diagnostic yield and treatment capabilities for recurrent OGIB. In this review, we will summarize the latest technologies for the diagnosis of OGIB, limitations of VCE, technological enhancement in VCE, and different management options for OGIB.
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Jacques J, Legros R, Chaussade S, Sautereau D. Endoscopic haemostasis: an overview of procedures and clinical scenarios. Dig Liver Dis 2014; 46:766-76. [PMID: 25022337 DOI: 10.1016/j.dld.2014.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/01/2014] [Accepted: 05/08/2014] [Indexed: 02/07/2023]
Abstract
Acute gastrointestinal bleeding is among the most urgent situations in daily gastroenterological practise. Endoscopy plays a key role in the diagnosis and treatment of such cases. Endoscopic haemostasis is probably the most important technical challenge that must be mastered by gastroenterologists. It is essential for both the management of acute gastrointestinal haemorrhage and the prevention of bleeding during high-risk endoscopic procedures. During the last decade, endoscopic haemostasis techniques and tools have grown in parallel with the number of devices available for endotherapy. Haemostatic powders, over-the-scope clips, haemostatic forceps, and other emerging technologies have changed daily practise and complement the standard available armamentarium (injectable, thermal, and mechanical therapy). Although there is a lack of strong evidence-based information on these procedures because of the difficulty in designing statistically powerful trials on this topic, physicians must be aware of all available devices to be able to choose the best haemostatic tool for the most effective procedure. We herein present an overview of procedures and clinical scenarios to optimise the management of gastrointestinal bleeding in daily practise.
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Affiliation(s)
- Jérémie Jacques
- Gastroenterology Department, University Hospital of Limoges, Limoges, France.
| | - Romain Legros
- Gastroenterology Department, University Hospital of Limoges, Limoges, France
| | | | - Denis Sautereau
- Gastroenterology Department, University Hospital of Limoges, Limoges, France
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46
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Patwardhan VR, Cardenas A. Review article: the management of portal hypertensive gastropathy and gastric antral vascular ectasia in cirrhosis. Aliment Pharmacol Ther 2014; 40:354-62. [PMID: 24889902 DOI: 10.1111/apt.12824] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/12/2014] [Accepted: 05/14/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are important causes of both acute and chronic gastrointestinal bleeding in patients with cirrhosis. AIM To review the current management of PHG and GAVE. METHODS PubMed was searched for English language articles using the key words 'GAVE', 'gastric antral vascular ectasia', 'cirrhosis', 'gastrointestinal bleeding', 'acute', 'chronic', 'portal hypertensive gastropathy', 'watermelon stomach', 'radiofrequency ablation', 'band ligation', 'thermoablation' and 'TIPSS'. RESULTS GAVE and PHG are both encountered in patients with cirrhosis. They can be seen in asymptomatic patients and in those with either acute or chronic gastrointestinal bleeding. PHG, by definition, requires the presence of portal hypertension, with or without cirrhosis, whereas GAVE requires neither cirrhosis nor portal hypertension. They can often be diagnosed on endoscopic appearance alone, but may require biopsy in certain cases. The treatment of PHG is aimed at reducing hepatic venous pressure gradients, most often by pharmacologic means, but may require shunt procedures in severe cases. Management of GAVE on the other hand is predominantly endoscopic, focusing on various ablative techniques. CONCLUSIONS Gastric antral vascular ectasia and portal hypertensive gastropathy are distinct entities and are both encountered in cirrhotic patients. Management of portal hypertensive gastropathy is centred on reduction in portal pressures, whereas treatment of gastric antral vascular ectasia is predominantly endoscopic.
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47
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Ahn Y, Wang TKM, Dunlop J. Treatment resistant gastric antral vascular ectasia in a patient undergoing haemodialysis. J Ren Care 2014; 40:263-5. [PMID: 24965484 DOI: 10.1111/jorc.12077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Gastric antral vascular ectasia (GAVE) is an important cause of upper gastrointestinal bleeding and has a high prevalence in patients with renal insufficiency. We report the first documented case of a 52-year-old patient on haemodialysis with GAVE refractory to repeated endoscopic argon plasma coagulation (APC) therapy and highlight the difficulties in its management. We recognise the need for further studies to investigate the optimal management of this condition and suggest alternative treatment strategies to be considered in patients with APC refractory GAVE, such as endoscopic band ligation and changing dialysis modality.
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Affiliation(s)
- Yeri Ahn
- Department of Renal Medicine, Middlemore Hospital, South Auckland, Papatoetoe, New Zealand
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Naidu H, Huang Q, Mashimo H. Gastric antral vascular ectasia: the evolution of therapeutic modalities. Endosc Int Open 2014; 2:E67-73. [PMID: 26135263 PMCID: PMC4423327 DOI: 10.1055/s-0034-1365525] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 01/08/2014] [Indexed: 01/10/2023] Open
Abstract
Gastric Antral Vascular Ectasia (GAVE) may be an enigmatic source of non-variceal upper GI bleeding associated with various systemic diseases such as connective tissue disorders, liver disease, and chronic renal failure. Successful treatment of GAVE continues to be a challenge and has evolved through the years. Currently, given the rapid response, safety, and efficacy, endoscopic ablative modalities have largely usurped medical treatments as first-line therapy, particularly using argon plasma coagulation. However, other newer ablative modalities such as radiofrequency ablation, cryotherapy, and band ligations are promising. This paper is an overview of GAVE and its various endoscopic and medical therapies.
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Affiliation(s)
- Harini Naidu
- Department of Internal Medicine, Boston University Medical Center, Boston, Massachusetts, United States,Corresponding author Harini Naidu, MD Department of Internal MedicineBoston University Medical Center72 East Concord StreetEvans 124BostonMA 02118United States
| | - Qin Huang
- Department of Gastroenterology, VA Boston Healthcare System, Boston, Massachusetts, United States,Department of Pathology, Harvard Medical School, Boston, Massachusetts, United States
| | - Hiroshi Mashimo
- Department of Gastroenterology, VA Boston Healthcare System, Boston, Massachusetts, United States,Department of Pathology, Harvard Medical School, Boston, Massachusetts, United States
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Long-term treatment outcome of patients with gastric vascular ectasia treated with argon plasma coagulation. Eur J Gastroenterol Hepatol 2014; 26:588-93. [PMID: 24743501 DOI: 10.1097/meg.0000000000000047] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Gastric vascular ectasia (VE) is an uncommon cause of upper gastrointestinal bleeding. Long-term data on the efficacy of argon plasma coagulation (APC) for the treatment of gastric VE are lacking. METHODS We retrospectively identified consecutive patients, between January 2005 and December 2010, treated with APC for an index diagnosis of gastric VE. Clinical and endoscopic features and APC treatment success were recorded. Treatment success was determined by resolution of symptoms and stabilization of the hemoglobin level at 30% above baseline. RESULTS A total of 62 patients [28 (45.2%) male] with a mean age of 72.6 ± 12.8 years, who had undergone 159 upper endoscopies (mean 2.6, range 1-10), including 140 APC sessions (mean 2.3, range 1-10), were identified. The duration of follow-up was 46.9 ± 26.5 months. Treatment success was achieved in 16 (25.8%) patients. Predictors of success included older age, focal pattern, lack of comorbid liver failure or collagen vascular disease, use of antiplatelet or anticoagulant drugs, and lower baseline hemoglobin level. Of the patients, 26 (41.9%) died during follow-up. CONCLUSION APC is safe and effective for the initial management of gastric VE; however, most patients do not experience long-term resolution of upper gastrointestinal bleeding and anemia.
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50
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Swanson E, Mahgoub A, MacDonald R, Shaukat A. Medical and endoscopic therapies for angiodysplasia and gastric antral vascular ectasia: a systematic review. Clin Gastroenterol Hepatol 2014; 12:571-82. [PMID: 24013107 DOI: 10.1016/j.cgh.2013.08.038] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 07/24/2013] [Accepted: 08/19/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Few studies have compared the efficacy and complications of endoscopic or medical therapies for bleeding angiodysplasias or gastric antral vascular ectasias (GAVE). We conducted a systematic review to evaluate therapies. METHODS We performed a PubMed search for studies (written in English from January 1, 1980, through January 1, 2013) of medical or endoscopic treatment of bleeding angiodysplasias and GAVE. Measured outcomes included levels of hemoglobin, transfusion requirements, rebleeding rates, complications, treatment failures, and overall mortality. RESULTS We analyzed data from 63 studies that met inclusion criteria; 50 evaluated endoscopic treatment (1790 patients), 13 evaluated medical treatment (392 patients), and 12 were comparative studies. In patients with angiodysplasias, the combination of estrogen and progesterone did not significantly reduce bleeding episodes, compared with placebo (0.7/y vs 0.9/y, respectively), and increased mortality, compared with conservative therapy (33% vs 21%). A higher percentage of patients receiving octreotide were free of rebleeding at 1 and 2 years vs placebo (77% vs 55% and 68% vs 36%, respectively; P = .03). Thalidomide reduced the number of bleeding episodes (-8.96/y), compared with iron therapy (-1.38/y, P < .01), but neither treatment reduced mortality. More patients with GAVE treated by endoscopic band ligation were free from rebleeding (92%) than those treated with argon plasma coagulation (32%, P = .01). CONCLUSIONS In a systematic review, we found a low quality of evidence to support treatment of angiodysplasias with thalidomide or the combination of estrogen and progesterone and insufficient evidence to support treatment with octreotide. There is also insufficient evidence for endoscopic therapy of angiodysplasia or GAVE. Well-designed randomized controlled trials are needed to study the efficacy and complications of medical and endoscopic treatments for patients with angiodysplasias or GAVE.
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Affiliation(s)
- Eric Swanson
- Department of Medicine, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota
| | - Amar Mahgoub
- Department of Medicine, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota; Section of Gastroenterology, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota
| | - Roderick MacDonald
- Minnesota Evidence based Practice Center, Center for Chronic Disease and Outcome Research, Minneapolis, Minnesota
| | - Aasma Shaukat
- Department of Medicine, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota; Section of Gastroenterology, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota.
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