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Peng M, Guo X, Yi F, Romeiro FG, Mancuso A, Qi X. Pharmacotherapy for the Treatment of Gastric Antral Vascular Ectasia: A Narrative Review. Adv Ther 2021; 38:5065-5077. [PMID: 34524644 DOI: 10.1007/s12325-021-01912-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/31/2021] [Indexed: 02/07/2023]
Abstract
Gastric antral vascular ectasia (GAVE) is an uncommon clinical entity leading to recurrent gastrointestinal bleeding. There is no consensus regarding treatment of GAVE. Endoscopic therapy is the preferred treatment option, but has a fairly high recurrence rate. Surgical resection can completely resolve GAVE, but is invasive with a relatively high risk of postoperative complications. Recently, the role of pharmacotherapy for GAVE has been recognized. However, the evidence is limited to scattered case reports or small case series. This review comprehensively summarizes the efficacy and side effects of drugs commonly used for the treatment of GAVE, including octreotide, cyproheptadine, cyclophosphamide, prednisolone, estrogen-progesterone, thalidomide, bevacizumab, and tranexamic acid.
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Affiliation(s)
- Mengyuan Peng
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China
- Postgraduate College, Jinzhou Medical University, Jinzhou, People's Republic of China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China
| | - Fangfang Yi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China
| | - Fernando Gomes Romeiro
- Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Av. Prof. Mário Rubens Guimarães Montenegro, s/n, Distrito de Rubião Jr., Botucatu, SP, 18608917, Brazil
| | - Andrea Mancuso
- Medicina Interna 1, ARNAS Civico, Di Cristina, Benfratelli, Piazzale Leotta 4, Palermo, Italy
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China.
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Aveiro M, Rodrigues T, Rabadão T, Ferreira F, Teixeira M, Oliveira A, Vasconcelos I. The Use of Thalidomide in Severe Refractory Anaemia Due to Gastric Antral Vascular Ectasia (GAVE) in Cirrhosis? Eur J Case Rep Intern Med 2021; 7:002099. [PMID: 33457370 DOI: 10.12890/2020_002099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/28/2020] [Indexed: 01/17/2023] Open
Abstract
Gastric antral vascular ectasia (GAVE) is a rare cause of upper gastrointestinal bleeding associated with cirrhosis. The first-line treatment is endoscopic therapy with argon plasma coagulation (APC). There is a high recurrence rate, but some evidence suggests that thalidomide could play an important role in controlling refractory anaemia due to GAVE. The authors present the case of a cirrhotic patient with a recent diagnosis of GAVE, who underwent multiple endoscopic treatments and blood transfusions because of haematemesis. The patient started thalidomide and 6 months later, there was no recurrence of haematemesis and haemoglobin levels were stable, with no reported adverse effects. LEARNING POINTS The chronic bleeding associated with gastric antral vascular ectasia (GAVE) presenting with cirrhosis is more severe than that associated with portal hypertensive gastropathy.Argon plasma coagulation remains the first-line treatment, but GAVE has a high recurrence rate.Thalidomide could be an effective and safe option for recurrent bleeding due to GAVE in patients with cirrhosis.
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Affiliation(s)
- Marcelo Aveiro
- Department of Internal Medicine, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Tatiana Rodrigues
- Department of Internal Medicine, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Tiago Rabadão
- Department of Internal Medicine, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Filipa Ferreira
- Department of Internal Medicine, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Mariana Teixeira
- Department of Internal Medicine, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Ana Oliveira
- Department of Internal Medicine, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Inês Vasconcelos
- Department of Family Medicine, USF Atlântico Norte, Gafanha da Nazaré, Portugal
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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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Patel A, Patel S, Wickremesinghe PC, Vadada D. Radiofrequency ablation using Barrx ® for the endoscopic treatment of gastric antral vascular ectasia: a series of three cases and a review of the literature on treatment options. Clin Exp Gastroenterol 2017; 10:113-120. [PMID: 28744150 PMCID: PMC5513699 DOI: 10.2147/ceg.s80241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Gastric antral vascular ectasia (GAVE), also known as "watermelon stomach", is an uncommon condition, which can cause gastrointestinal bleeding due to rupture of blood vessels that line the stomach. The pathogenesis of GAVE remains unclear; however it is thought that hemodynamic changes, mechanical stress, and autoimmune factors all have a part to play. A range of conditions are also commonly associated with the syndrome, such as portal hypertensive gastropathy, liver cirrhosis, and autoimmune disorders. Less commonly, chronic renal failure, cardiac diseases, and bone marrow transplantation have coexisted with GAVE. The diagnosis is usually based on visualization of the tissue upon endoscopy; however, histology plays a role in uncertain cases. The typical "watermelon" appearance relates to the tissue having a striped appearance radiating out from the pylorus. Medical treatment has failed to show satisfactory results and surgery is usually considered as a last resort, due to its increased risk for complications and mortality. Lasers and argon plasma coagulation have been used recently, and been shown to be as effective as surgery and a safer option. We present three cases of gastric antral vascular ectasia treated at our institution with radiofrequency ablation and review the literature on treatment modalities for GAVE.
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Affiliation(s)
- Anish Patel
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Sunil Patel
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | | | - Deepak Vadada
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
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Hemorrhage from Extra-Antral Gastric Antral Vascular Ectasia in a Patient with Duodenal Heterotopic Gastric Mucosa. Case Rep Gastrointest Med 2016; 2016:4325302. [PMID: 27830096 PMCID: PMC5088272 DOI: 10.1155/2016/4325302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 09/26/2016] [Indexed: 12/22/2022] Open
Abstract
Gastric antral vascular ectasias (GAVE) have been increasingly recognized as an uncommon cause of chronic gastrointestinal bleeding and anemia, although their underlying pathogenesis is not completely well understood. Heterotopic gastric mucosa (HGM) has been reported to occur at various sites along the gastrointestinal tract and although relatively common, it is often asymptomatic. We report a case of a 60-year-old woman with a prior history of GAVE who developed melena and symptomatic anemia during her hospitalization following cardiac catheterization. Initial EGD demonstrated nonbleeding antral GAVE and a newly discovered duodenal mass. Duodenal mass biopsies were ultimately notable for HGM along with histologic features of extra-antral GAVE. The patient required blood transfusions and consequently had a small bowel endoscopy notable for fresh blood in the proximal small bowel. The patient underwent a small bowel push enteroscopy which demonstrated active bleeding of the duodenal mass and overlying oozing GAVE, which was cauterized with Argon-Plasma Coagulation with adequate hemostasis. We present for the first time a novel association between GAVE and HGM. Our case illustrates that extra-antral GAVE may occur with HGM in the duodenum. We explore potential mechanisms by which HGM may be involved in the pathogenesis of GAVE.
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Gastric Antral Vascular Ectasia in Systemic Sclerosis: Current Concepts. Int J Rheumatol 2015; 2015:762546. [PMID: 26633973 PMCID: PMC4655054 DOI: 10.1155/2015/762546] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/20/2015] [Accepted: 10/20/2015] [Indexed: 12/20/2022] Open
Abstract
Introduction. Gastric antral vascular ectasia (GAVE) is a rare entity with unique endoscopic appearance described as “watermelon stomach.” It has been associated with systemic sclerosis but the pathophysiological changes leading to GAVE have not been explained and still remain uncertain. Methods. Databases Medline, Scopus, Embase, PubMed, and Cochrane were searched for relevant papers. The main search words were “Gastric antral vascular ectasia,” “Watermelon Stomach,” “GAVE,” “Scleroderma,” and “Systemic Sclerosis.” Fifty-four papers were considered for this review. Results. GAVE is a rare entity in the spectrum of manifestations of systemic sclerosis with unknown pathogenesis. Most patients with systemic sclerosis and GAVE present with asymptomatic anemia, iron deficiency anemia, or heavy acute gastrointestinal bleeding. Symptomatic therapy and endoscopic ablation are the first-line of treatment. Surgical approach may be recommended for patients who do not respond to medical or endoscopic therapies. Conclusion. GAVE can be properly diagnosed and treated. Early diagnosis is key in the management of GAVE because it makes symptomatic therapies and endoscopic approaches feasible. A high index of suspicion is critical. Future studies and a critical review of the current findings about GAVE are needed to understand the role of this condition in systemic sclerosis.
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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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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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10
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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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11
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Lam A, Lam SSH, Chang DWH, Badov D. Octreotide Use in Gastric Antral Vascular Ectasia. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2013. [DOI: 10.1002/j.2055-2335.2013.tb00279.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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McGorisk T, Krishnan K, Keefer L, Komanduri S. Radiofrequency ablation for refractory gastric antral vascular ectasia (with video). Gastrointest Endosc 2013; 78:584-8. [PMID: 23660565 DOI: 10.1016/j.gie.2013.04.173] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 04/11/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) is a cause of upper GI bleeding and chronic anemia. Although upper endoscopy with argon plasma coagulation (APC) is an accepted therapy for GAVE, many patients continue to bleed and remain transfusion dependent after therapy. Radiofrequency ablation (RFA) may provide an alternative therapeutic option for GAVE. OBJECTIVE To determine the efficacy and safety of RFA for patients with GAVE who remain transfusion dependent after APC treatment. DESIGN Open-label prospective cohort study of patients with GAVE refractory to APC. SETTING Academic tertiary referral center. PATIENTS GAVE patients with previous failed APC therapy, chronic anemia, and transfusion dependence. INTERVENTIONS Endoscopic RFA to the gastric antrum using the HALO(90) ULTRA ablation catheter until transfusion independence is achieved or a maximum of 4 sessions are performed. MAIN OUTCOME MEASUREMENTS Transfusion requirements before and after RFA. Secondary outcomes are hemoglobin before and 6 months after RFA completion, number of RFA sessions, and complications. RESULTS Twenty-one patients underwent at least 1 RFA session with ablation of GAVE lesions. At 6 months after completion of the course of RFA therapy, 18 of 21 patients (86%) were transfusion independent. Mean hemoglobin increased from 7.8 to 10.2 in responders (n = 18). Two adverse events occurred (minor acute bleeding and superficial ulceration); both resolved without intervention. LIMITATIONS Single-center, single-operator, and nonrandomized design. CONCLUSIONS RFA is safe and effective for treating patients with refractory GAVE after attempted APC.
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Affiliation(s)
- Tim McGorisk
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Yoshida H, Takahashi H, Akoshima H, Chida N, Noguchi K, Tanabe N, Mano Y, Ukai K, Tadokoro K. Successful treatment of refractory gastric antral vascular ectasia using transcatheter arterial embolization. Clin J Gastroenterol 2013; 6:231-6. [DOI: 10.1007/s12328-013-0385-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 04/30/2013] [Indexed: 12/11/2022]
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Hirayama M, Azuma E, Nakazawa A, Iwamoto S, Toyoda H, Komada Y. Simultaneous occurrence of gastric antral vascular ectasia and protein-losing enteropathy in chronic graft-versus-host disease. Int J Hematol 2013; 97:529-34. [DOI: 10.1007/s12185-013-1279-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 01/16/2013] [Accepted: 01/20/2013] [Indexed: 12/22/2022]
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Fuccio L, Mussetto A, Laterza L, Eusebi LH, Bazzoli F. Diagnosis and management of gastric antral vascular ectasia. World J Gastrointest Endosc 2013; 5:6-13. [PMID: 23330048 PMCID: PMC3547119 DOI: 10.4253/wjge.v5.i1.6] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 09/26/2012] [Accepted: 12/01/2012] [Indexed: 02/05/2023] Open
Abstract
Gastric antral vascular ectasia (GAVE) is an uncommon but often severe cause of upper gastrointestinal (GI) bleeding, responsible of about 4% of non-variceal upper GI haemorrhage. The diagnosis is mainly based on endoscopic pattern and, for uncertain cases, on histology. GAVE is characterized by a pathognomonic endoscopic pattern, mainly represented by red spots either organized in stripes radially departing from pylorus, defined as watermelon stomach, or arranged in a diffused-way, the so called honeycomb stomach. The histological pattern, although not pathognomonic, is characterized by four alterations: vascular ectasia of mucosal capillaries, focal thrombosis, spindle cell proliferation and fibrohyalinosis, which consist of homogeneous substance around the ectatic capillaries of the lamina propria. The main differential diagnosis is with Portal Hypertensive Gastropathy, that can frequently co-exists, since about 30% of patients with GAVE co-present a liver cirrhosis. Autoimmune disorders, mainly represented by Reynaud’s phenomenon and sclerodactyly, are co-present in about 60% of patients with GAVE; other autoimmune and connective tissue disorders are occasionally reported such as Sjogren’s syndrome, systemic lupus erythematosus, primary biliary cirrhosis and systemic sclerosis. In the remaining cases, GAVE syndrome has been described in patients with chronic renal failure, bone marrow transplantation and cardiac diseases. The pathogenesis of GAVE is still obscure and many hypotheses have been proposed such as mechanical stress, humoural and autoimmune factors and hemodynamic alterations. In the last two decades, many therapeutic options have been proposed including surgical, endoscopic and medical choices. Medical therapy has not clearly shown satisfactory results and surgery should only be considered for refractory severe cases, since this approach has significant mortality and morbidity risks, especially in the setting of portal hypertension and liver cirrhosis. Endoscopic therapy, particularly treatment with Argon Plasma Coagulation, has shown to be as effective and also safer than surgery, and should be considered the first-line treatment for patients with GAVE-related bleeding.
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Affiliation(s)
- Lorenzo Fuccio
- Lorenzo Fuccio, Liboria Laterza, Leonardo Henry Eusebi, Franco Bazzoli, Department of Clinical Medicine, S.Orsola-Malpighi University Hospital, 40138 Bologna, Italy
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16
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Gastric antral vascular ectasia in systemic sclerosis. Int J Rheumatol 2011; 2011:305238. [PMID: 22121374 PMCID: PMC3216371 DOI: 10.1155/2011/305238] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 08/26/2011] [Indexed: 12/13/2022] Open
Abstract
Gastric antral vascular ectasia is a not so well-understood, and more rare, gastrointestinal manifestation of Systemic Sclerosis which can lead to chronic anemia. A high suspicion and better understanding of this rare manifestation is needed for early detection and treatment. Therapeutic regiments include iron supplementation with acid suppressive therapy, while endoscopic intervention has been shown to be successful in most cases, with gastrectomy or antrectomy rarely needed.
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17
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Ripoll C, Garcia-Tsao G. The management of portal hypertensive gastropathy and gastric antral vascular ectasia. Dig Liver Dis 2011; 43:345-51. [PMID: 21095166 DOI: 10.1016/j.dld.2010.10.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 10/11/2010] [Indexed: 02/08/2023]
Abstract
Portal hypertensive gastropathy and gastric antral vascular ectasia are gastric mucosal lesions that can cause chronic gastrointestinal haemorrhage and, consequently, chronic anaemia, in patients with cirrhosis. Although chronic anaemia is the most common clinical manifestation, these entities may also lead to acute gastrointestinal bleeding. Despite similar clinical manifestations, their pathophysiology and management are entirely different. 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 portal hypertensive gastropathy is based on portal-hypotensive pharmacological treatment whilst gastric antral vascular ectasia benefits from endoscopic therapy. More invasive options should be reserved for refractory cases.
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Affiliation(s)
- Cristina Ripoll
- Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
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18
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Ripoll C, Garcia-Tsao G. Management of gastropathy and gastric vascular ectasia in portal hypertension. Clin Liver Dis 2010; 14:281-95. [PMID: 20682235 PMCID: PMC2916868 DOI: 10.1016/j.cld.2010.03.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Portal hypertensive gastropathy and gastric antral vascular ectasia may cause gastrointestinal hemorrhage in patients with portal hypertension. Whereas the former presents exclusively in patients with portal hypertension, gastric antral vascular ectasia can also be observed in patients with other conditions. Diagnosis is established with upper gastrointestinal endoscopy, although some cases may require a biopsy to confirm the diagnosis. The most frequent manifestation is ferropenic anemia, which may become transfusion dependent. Treatment in portal hypertensive gastropathy is focused on portal pressure reducing drugs, mainly nonselective beta-blockers, whereas in gastric antral vascular ectasia treatment is based on endoscopic ablation. More invasive options can be used if first-line therapies fail, although these should be evaluated on a case-by-case basis.
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Affiliation(s)
| | - Guadalupe Garcia-Tsao
- Corresponding author: Guadalupe Garcia-Tsao, M.D., Digestive Diseases Section, Yale University School of Medicine, 333 Cedar Street – 1080 LMP, New Haven, CT 06510, , Tph: 203 737 6063, Fax: 203 785-7273
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19
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Pljesa S, Golubovic G, Tomasevic R, Markovic R, Perunicic G. “Watermelon Stomach” in Patients on Chronic Hemodialysis. Ren Fail 2009; 27:643-6. [PMID: 16153007 DOI: 10.1080/08860220500200890] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
"Watermelon stomach" is a common name for gastric antral vascular ectasia (GAVE syndrome). This endoscopic finding is characterized by the appearance of parallel longitudinal red columns along mucosal folds, along with capillars dilatation and hemorrhagy. Finding reliable method for its recognition is of paramount importance. Patient B.D., a 54-year-old woman, developed renal failure, which led to hemodialysis treatment, on the basis of pyelonephritis chronica. As a consequence of the gastrointestinal bleeding, the patient had black stools and developed severe anemia. The endoscopic finding showed the existence of visible columns of vessels transversing the antrum in longitudinal folds and converging in the pylorus, with clear red spots and surrounding hyperemy covered by drops of fresh blood. The diagnosis of "watermelon stomach" was confirmed after the pathohistological examination of the tissue taken at the biopsy, followed by total gastrectomy. Postoperative status was normal, without gastrointestinal hemorrhagia, and she went on with hemodialysis. Before the surgery she received 105 blood transfusions, and after surgical treatment she has received only 18 so far. At the moment she is in good health condition, and on hemodialysis. The reason we have reported this case of "watermelon stomach" syndrome in patient with chronic renal failure is to indicate that this rare anomaly of gastric blood vessels can lead to gastrointestinal blood loss in these patients. Since it is often the reason for many wrong diagnoses, it should be also taken into consideration in cases like these.
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Affiliation(s)
- Steva Pljesa
- Department of Nephrology and Hemodialysis, University Hospital Zemun, Vukova 9, Zemun, Belgrade 11080, Serbia and Montenegro.
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Abstract
BACKGROUND Although relatively rare, gastric vascular anomalies can be recognized as a source of both chronic and acute blood loss, most often presenting as long term iron deficiency anemia, rarely as severe acute gastrointestinal bleeding. CASE REPORT We present five patients with various gastric vascular anomalies, diagnosed during the year of 2003. in the Clinical Hospital Center Zemun. The diagnosis was based on endoscopic appearances, clinical history and characteristic histological findings. Gastric vascular anomalies presented in our review were: portal hypertensive gastropathy, gastric antral vascular ectasia, angiodysplasia, hereditary hemorrhagic telangiectasia and Dieulafoy lesion. The used treatment modalities included surgery and various endoscopic techniques (schlerotherapy, argon plasma coagulation). CONCLUSION Patients presented with chronic iron deficiency anemia or acute and recurrent gastrointestinal hemorrhage should be considered as having one of gastric vascular anomalies.
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Lecleire S, Ben-Soussan E, Antonietti M, Goria O, Riachi G, Lerebours E, Ducrotté P. Bleeding gastric vascular ectasia treated by argon plasma coagulation: a comparison between patients with and without cirrhosis. Gastrointest Endosc 2008; 67:219-25. [PMID: 18226684 DOI: 10.1016/j.gie.2007.10.016] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 10/02/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastric vascular ectasia (GVE) is an uncommon etiology of GI bleeding. GVE can affect not only patients with cirrhosis but also patients with a variety of chronic diseases. OBJECTIVE The aim of the study was to compare clinical and endoscopic patient characteristics and responses to treatment by argon plasma coagulation (APC) of bleeding GVE between patients with cirrhosis and noncirrhotic patients. DESIGN Retrospective study of consecutive patients. PATIENTS Between January 2001 and December 2005, 30 patients were treated by APC for bleeding GVE. INTERVENTIONS Clinical and endoscopic features and APC treatment success were compared between patients with cirrhosis (group 1) and noncirrhotic patients (group 2). MAIN OUTCOME MEASUREMENTS Endoscopic treatment efficacy was assessed on the recurrence of symptoms after APC. RESULTS Seventeen patients were cirrhotic and 13 had no cirrhosis. Cirrhotic patients presented more frequently with overt bleeding (65% vs 15%) and noncirrhotic patients with occult bleeding with iron deficiency anemia (35% vs 85%, P= .01). Endoscopy in noncirrhotic patients revealed more frequently a "watermelon" appearance (23.5% vs 76.9%, P= .008). Endoscopic treatment by APC was successful in 83.3% of patients (88.2% vs 76.9%, not significant). Patients from group 2 required significantly more APC sessions to achieve a complete treatment (2.18 vs 3.77, P= .04). CONCLUSIONS APC treatment of bleeding GVE was efficient and safe in cirrhotic and noncirrhotic patients in more than 80% of cases. Noncirrhotic patients required significantly more APC sessions to achieve a complete treatment. An endoscopic watermelon appearance and the use of antiplatelet drugs were associated with failure of APC.
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Affiliation(s)
- Stéphane Lecleire
- Department of Hepato-Gastroenterology and Nutrition, Endoscopy Unit, ADEN-EA3234/IFRMP23 Research Group, Rouen University Hospital Charles-Nicolle, Rouen, France
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22
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Abstract
Progressive systemic sclerosis (PSS) is a chronic multisystem disease characterized by excess deposition of connective tissue in skin and internal organs, associated with microvasculature changes and immunologic abnormalities. Involvement of the gastrointestinal tract may occur in 2 stages, a neuropathic disorder followed by a myopathy. Gastric emptying is delayed in 10% to 75% of patients and correlates with symptoms of early satiety, bloating, and emesis. Compliance of the fundus is increased although perception of fullness is normal. Myoelectric abnormalities have been found in some studies. Treatments include metoclopramide, cisapride, and erythromycin. Bleeding from telangiectasias and watermelon stomach is treated endoscopically. Small bowel involvement in PSS occurs in 17% to 57% of patients. The migrating motor complexes are reduced or absent, predisposing to bacterial overgrowth. Malabsorption may also be due to pancreatic insufficiency. Barium enemas demonstrate pancolonic involvement in 10% to 50% of patients with PSS. Wide-mouthed diverticuli, involving all layers of the intestinal wall, are characteristic. Pseudoobstruction may respond to octreotide or prucalopride therapy. Complications include pneumatosis cystoides intestinalis, stercoral ulcerations, and perforation. Fecal incontinence may be due to dysfunction of the internal anal sphincter, a smooth muscle responsible for most of the resting anal sphincter pressure. Anal manometry may show a reduction or loss of the rectoanal inhibitory reflex. Treatments include biofeedback, sacral nerve stimulation, and surgery. PSS involves the gastrointestinal tract from the mouth to the anus. Studies are needed to define effective treatments in these diseases, which cause great morbidity.
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Terawaki H, Kobayashi S, Kato JI, Kusaka M, Yamada Y, Nakao M, Takane K, Yamamoto R, Hamaguchi A, Mogami T, Kato T, Ogura M, Hosoya T, Takao M. A case report of hemodiaysis patient who presented recurrent bleeding from gastric antral vascular ectasia (GAVE) associated with liver cirrhosis: The effectiveness of trans-arterial embolization to bilateral gastric arteries. ACTA ACUST UNITED AC 2008. [DOI: 10.4009/jsdt.41.803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Chaves DM, Sakai P, Oliveira CV, Cheng S, Ishioka S. Watermelon stomach: clinical aspects and treatment with argon plasma coagulation. ARQUIVOS DE GASTROENTEROLOGIA 2007; 43:191-5. [PMID: 17160233 DOI: 10.1590/s0004-28032006000300007] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2005] [Accepted: 01/26/2006] [Indexed: 01/23/2023]
Abstract
BACKGROUND Gastric antral vascular ectasia is a disorder whose pathogenetic mechanism is unknown. The endoscopic treatment with argon plasma coagulation has been considered one of the best endoscopic therapeutic options. AIM To analyze the endoscopic and clinical features of gastric antral vascular ectasia and its response to the argon plasma coagulation treatment. PATIENTS AND METHODS Eighteen patients were studied and classified into two groups: group 1--whose endoscopic aspect was striped (watermelon) or of the diffuse confluent type; group 2--diffuse spotty nonconfluent endoscopic aspect. RESULTS Group 1 with eight patients, all having autoimmune antibodies, but one, whose antibodies were not searched for. Three were cirrhotic and three had hypothyroidism. All had gastric mucosa atrophy. In group 2, with 10 patients, all had non-immune liver disease, with platelet levels below 90,000. Ten patients were submitted to argon plasma coagulation treatment, with 2 to 36 months of follow-up. Lesions recurred in all patients who remained in the follow-up program and one did not respond to treatment for acute bleeding control. CONCLUSION There seem to be two distinct groups of patients with gastric antral vascular ectasia: one related to immunologic disorders and other to non-immune chronic liver disease and low platelets. The endoscopic treatment using argon plasma coagulation had a high recurrence in the long-term evaluation.
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Affiliation(s)
- Dalton M Chaves
- Endoscopy Service, Medical School, University of São Paulo, São Paulo, SP, Brazil.
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25
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Szilagyi A, Ghali MP. Pharmacological therapy of vascular malformations of the gastrointestinal tract. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2006; 20:171-8. [PMID: 16550261 PMCID: PMC2582970 DOI: 10.1155/2006/859435] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Vascular malformation (AVM) in the gastrointestinal tract is an uncommon, but not rare, cause of bleeding and iron deficiency anemia, especially in an aging population. While endoscopic coagulative therapy is the method of choice for controlling bleeding, a substantial number of cases require additional therapy. Adjunctive or even primary phamacotherapy may be indicated in recurrent bleeding. However, there is little evidence-based proof of efficacy for any agent. The bulk of support is derived from anecdotal reports or case series. The present review compares the outcome of AVM after no intervention, coagulative therapy or focus on pharmacological agents. Most of the literature encompasses two common AVMs, angiodysplasia and hereditary hemorrhagic telangiectasia. Similarly, the bulk of information evaluates two therapies, hormones (estrogen and progesterone) and the somatostatin analogue octreotide. Of these, the former is the only therapy evaluated in randomized trials, and the results are conflicting without clear guidelines. The latter therapy has been reported only as case reports and case series without prospective trials. In addition, other anecdotally used medications are discussed.
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Affiliation(s)
- Andrew Szilagyi
- Division of Gastroenterology, Department of Medicine, Sir Mortimer B Davis Jewish General Hospital, McGill University School of Medicine, Montreal, Quebec.
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26
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Yoshino S, Matsumoto T, Esaki M, Yada S, Iida M. DIFFUSE ANTRAL VASCULAR ECTASIA OF THE STOMACH EFFECTIVELY TREATED BY ESTROGEN-PROGESTERONE THERAPY. Dig Endosc 2005. [DOI: 10.1111/j.1443-1661.2005.00555.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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27
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Yoshino N, Ishihara S, Rumi MAK, Ortega-Cava CF, Yuki T, Kazumori H, Takazawa S, Okamoto H, Kadowaki Y, Kinoshita Y. Interleukin-8 regulates expression of Reg protein in Helicobacter pylori-infected gastric mucosa. Am J Gastroenterol 2005; 100:2157-66. [PMID: 16181363 DOI: 10.1111/j.1572-0241.2005.41915.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIM Chronic inflammation induced by Helicobacter pylori infection is closely associated with epithelial cell proliferation and apoptosis, which are related to cellular turnover in gastric mucosa. Reg protein is a regenerating gene product and a potent growth factor for gastric mucosal cells, however, little is known regarding its association with the pathogenesis of H. pylori infection. The aim of this study was to investigate Reg protein production and its regulation in H. pylori-associated gastritis. METHODS Gastric fundic biopsy samples were taken from patients with and without H. pylori infection. In vivo expression of Reg protein was examined by Western blotting and immunohistochemistry methods. The effects of interleukin (IL)-8 on Reg protein expression and transcriptional activation of the Reg gene in ECC10 cells were investigated by Western blotting and luciferase assays, respectively. RESULTS Reg expression was found localized in the deeper part of gastric fundic glands and clearly shown in chromogranin A-positive cells in the gastric corpus. Semiquantitative immunohistochemistry and Western blotting results for Reg expression were significantly associated with polymorphonuclear neutrophil activity and chronic inflammation of gastric mucosa. IL-8 production in the gastric mucosa was significantly augmented by H. pylori infection, while IL-8 dose-dependently stimulated Reg protein production and Reg promoter activity in vitro in cultured ECC10 cells. CONCLUSION The present study showed for the first time that Reg protein may be a potent stimulator of gastric epithelial cells in H. pylori-infected human gastric mucosa stimulated by IL-8. Further, our findings provide evidence of a novel link between Reg protein and H. pylori infection, which may help explain the molecular mechanisms underlying H. pylori-associated diseases, including gastric cancer.
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Affiliation(s)
- Nagisa Yoshino
- Department of Gastroenterology and Hepatology, Shimane University, School of Medicine, Izumo, Japan
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28
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Sou S, Nagahama T, Nomura H, Matsubara F, Tanaka H, Matsui T, Yao T. Remarkable effectiveness of endoscopic argon plasma coagulation against diffuse antral vascular ectasia. Dig Endosc 2004. [DOI: 10.1111/j.1443-1661.2003.00331.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Mathou NG, Lovat LB, Thorpe SM, Bown SG. Nd:YAG laser induces long-term remission in transfusion-dependent patients with watermelon stomach. Lasers Med Sci 2004; 18:213-8. [PMID: 15042426 DOI: 10.1007/s10103-003-0284-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2003] [Accepted: 11/21/2003] [Indexed: 01/16/2023]
Abstract
Watermelon stomach (gastric antral vascular ectasia) is a rare cause of gastric bleeding which can render patients transfusion-dependent. Laser therapy can be used to stop bleeding but the long-term success of this approach is not well described. We present a retrospective analysis of 24 consecutive transfusion-dependent patients who were treated in a national referral centre with Nd:YAG laser over an 18 year period. Laser therapy stopped all bleeding in 20 patients (83%) after a median of two sessions. Median follow up was 55 months (range 9-127). Patients remained transfusion free for a median of 16 months and a second course of treatment succeeded in all those who re-bled. One gastric perforation occurred early in the series and two patients developed pyloric stenosis which was successfully treated with balloon pyloric dilatation. Oestrogens were not used in these patients. Our experience shows that long-term remission from blood transfusion is seen in most patients treated with Nd:YAG laser. If bleeding recurs, further laser treatment is usually successful.
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Affiliation(s)
- N G Mathou
- National Medical Laser Centre, Department of Surgery, Royal Free and University College Medical School, UCL, 67-73 Riding House Street, W1W 7EJ, London, UK
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30
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Sebastian S, O'Morain CA, Buckley MJM. Review article: current therapeutic options for gastric antral vascular ectasia. Aliment Pharmacol Ther 2003; 18:157-165. [PMID: 12869075 DOI: 10.1046/j.1365-2036.2003.01617.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Gastric antral vascular ectasia, or 'watermelon stomach', is a rare but important cause of gastrointestinal blood loss and anaemia, which has characteristic endoscopic and histological features. The pathogenesis of this condition remains unclear; however, many associated disorders have been documented. Various medical, surgical and endoscopic therapeutic modalities have been attempted with variable success. Leading contenders for the therapeutic modality of choice include hormonal therapy, endoscopic Nd:YAG laser and argon plasma coagulation. Randomized controlled trials to identify the ideal treatment method are lacking at present.
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Affiliation(s)
- S Sebastian
- Department of Gastroenterology, Adelaide and Meath Hospital, Trinity College, Dublin, Ireland
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31
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Novitsky YW, Kercher KW, Czerniach DR, Litwin DEM. Watermelon stomach: pathophysiology, diagnosis, and management. J Gastrointest Surg 2003; 7:652-61. [PMID: 12850679 DOI: 10.1016/s1091-255x(02)00435-3] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Watermelon Stomach (WS) has been increasingly recognized as an important cause of occult gastrointestinal blood loss. Clinically, patients develop significant iron deficiency anemia and are frequently transfusion dependent. The histologic hallmark of WS is superficial fibromuscular hyperplasia of gastric antral mucosa with capillary ectasia and microvascular thrombosis in the lamina propria. Endoscopic findings of the longitudinal antral folds containing visible columns of tortuous red ectatic vessels (watermelon stripes) are pathognomonic for WS. Trauma to the mucosal epithelium overlying engorged vessels by gastric acid or intraluminal food results in bleeding. Treatment options for WS include endoscopic, pharmacologic, and surgical approaches. Endoscopic therapy, including contact and non-contact thermal ablations of the angiodysplastic lesions, is the mainstay of conservative therapy. However, many patients fail endoscopic therapy and develop recurrent acute and chronic GI bleeding episodes. Surgical resection may be the only reliable method for achieving a cure and eliminating transfusion dependency. Traditionally, surgery was used only as a last resort after patients failed prolonged medical and/or endoscopic therapy. However, based on the experience garnered from the literature we recommend a more aggressive surgical approach in patients who fail a short trial of endoluminal therapy.
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Affiliation(s)
- Yuri W Novitsky
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA 01655, USA.
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32
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Lefkovitz Z, Cappell MS, Lookstein R, Mitty HA, Gerard PS. Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia. Med Clin North Am 2002; 86:1357-1399. [PMID: 12510457 DOI: 10.1016/s0025-7125(02)00080-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Major breakthroughs in catheter, guidewire, and other angiographic equipment currently allow interventional radiologists to diagnose massive life-threatening upper and lower GI hemorrhage and to stop the bleeding safely and effectively using superselective catheterization and microcoil embolization. Similarly, the interventional radiologist can treat acute intestinal ischemia safely and effectively with selective catheterization and papaverine administration and treat chronic mesenteric ischemia by percutaneous angioplasty and stent placement. A multidisciplinary approach, including the gastroenterologist, radiologist, and surgeon, is critical in managing GI bleeding and intestinal ischemia, particularly in patients at high risk or presenting as diagnostic dilemmas.
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Affiliation(s)
- Zvi Lefkovitz
- Department of Radiology, Mount Sinai Medical Center, Mount Sinai School of Medicine, New York, NY, USA
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33
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Affiliation(s)
- K W Burak
- University of Calgary Liver Unit and Gastrointestinal Research Group, Calgary, Alberta, Canada
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34
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Lorenzi AR, Johnson AH, Davies G, Gough A. Gastric antral vascular ectasia in systemic sclerosis: complete resolution with methylprednisolone and cyclophosphamide. Ann Rheum Dis 2001; 60:796-8. [PMID: 11454645 PMCID: PMC1753805 DOI: 10.1136/ard.60.8.796] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A case of severe, transfusion dependent anaemia in a 72 year old woman, which on endoscopy was found to be due to gastric antral vascular ectasia (GAVE), is reported. Repeated endoscopic sclerotherapy was ineffective. She subsequently developed Raynaud's phenomenon and on further investigation was found to have classical systemic sclerosis with lung involvement. Treatment with pulses of intravenous methylprednisolone and cyclophosphamide resulted in significant improvement in her pulmonary function tests and skin score. Coincidentally, her haemoglobin stabilised and further endoscopic examinations were normal. This is the first report of cyclophosphamide and methylprednisolone leading to complete and sustained resolution of GAVE in association with systemic sclerosis.
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Affiliation(s)
- A R Lorenzi
- Department of Rheumatology, Harrogate District Hospital, Harrogate, UK
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35
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Abstract
Among patients with acute gastrointestinal bleeding, older age is associated with an increased rate of comorbidity, greater medication use, and atypical clinical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding in the elderly a special and increasingly common clinical challenge. The unique features and common causes of upper and lower gastrointestinal bleeding in the elderly are reviewed. Important management issues considered include hemodynamic resuscitation; anticoagulation; and medical, surgical, and endoscopic therapy.
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Affiliation(s)
- J J Farrell
- Harvard Medical School, Boston, Massachusetts, USA
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36
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Garcia N, Sanyal AJ. Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2001; 4:163-171. [PMID: 11469974 DOI: 10.1007/s11938-001-0028-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Portal hypertensive gastropathy (PHG) causes both acute and chronic blood loss from the gastrointestinal tract in patients with portal hypertension. Gastric antral vascular ectasia (GAVE) is a distinct condition also associated with portal hypertension that can cause acute and chronic upper gastrointestinal blood loss. These conditions frequently, but not invariably, are diagnosed by upper endoscopy. Although they are fairly prevalent, only 15% to 20% of subjects experience symptomatic gastrointestinal blood loss. Acute gastrointestinal bleeding from PHG should first be treated with octreotide (100 mg bolus intravenously, followed by a 50 mg/h continuous intravenous infusion). If the bleeding does not stop or slow down appreciably within 24 to 48 hours, propranolol may be administered orally to those patients who are hemodynamically stable. Propranolol should be started at 40 mg/d orally in two divided doses. If the patient can tolerate the propranolol and is still bleeding, the dosage may be titrated up to the maximum tolerated amount. For those subjects who are unable to tolerate beta-blockers or continue to bleed despite beta-blocker therapy, transjugular intrahepatic portosystemic shunt (TIPS) is the next line of treatment. Portal decompressive surgery is reserved for those who are not candidates for TIPS and where the appropriate expertise is available. Prevention of chronic gastrointestinal blood loss from PHG should be attempted with beta-blockers, with the dosage titrated up to achieve a resting heart rate of approximately 60 beats per minute. In patients who do not respond to beta-blockers, a TIPS should be placed. The role of long-acting release octreotide in this setting is experimental. The primary treatment of actively bleeding GAVE as well as recurrent bleeding from GAVE is endoscopic ablation of the lesion using either argon plasma coagulation, neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, or heater probe. TIPS and beta-blockers are ineffective for the long-term prevention of recurrent bleeding from GAVE. For selected patients with severe recurrent bleeding or uncontrollable acute bleeding from GAVE, an antrectomy with Billroth I anastomosis may be considered.
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Affiliation(s)
- Nelson Garcia
- Division of Gastroenterology and Hepatology, Medical College of Virginia-Virginia Commonwealth University, PO Box 980711, Richmond, VA 23298-0711, USA.
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37
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Abstract
Aging is associated with an increased rate of comorbidity, greater medication use, and atypical clinical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding in older people a special and increasingly common clinical challenge. The unique features and common causes of upper and lower gastrointestinal bleeding in older people are reviewed. Important management issues considered include hemodynamic resuscitation, anticoagulation, and endoscopic and surgical therapy.
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Affiliation(s)
- J J Farrell
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, USA
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38
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Satomi E, Kaneko A, Nishimura Y, Michida T, Komori M, Iyoda K, Sugiyasu Y, Yuki N, Yamamoto K, Kurosawa K, Kato M, Ikeda M. Effect of endoscopic treatment of gastric antral vascular extasia associated with chronic liver disease. Dig Endosc 2000. [DOI: 10.1046/j.1443-1661.2000.00012.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Eriko Satomi
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Akira Kaneko
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Yoshiya Nishimura
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Tomoki Michida
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Masato Komori
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Kenya Iyoda
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Yasunori Sugiyasu
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Nobukazu Yuki
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Keiji Yamamoto
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Kazuhei Kurosawa
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Michio Kato
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Masahiro Ikeda
- Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
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Gürsoy M, Baysal C, Demirhan B, Moray G, Boyacioğlu S. Rectal vascular ectasia associated with watermelon stomach. Gastrointest Endosc 1999; 50:854-7. [PMID: 10570354 DOI: 10.1016/s0016-5107(99)70176-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- M Gürsoy
- Başkent University Faculty of Medicine, Department of Gastroenterology, Pathology, and General Surgery, Ankara, Turkey.
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40
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Nardone G, Rocco A, Balzano T, Budillon G. The efficacy of octreotide therapy in chronic bleeding due to vascular abnormalities of the gastrointestinal tract. Aliment Pharmacol Ther 1999; 13:1429-36. [PMID: 10571598 DOI: 10.1046/j.1365-2036.1999.00647.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The treatment of angiodysplasia and watermelon stomach, vascular abnormalities implicated in gastrointestinal bleeding of obscure origin, is a major clinical problem. AIM To determine the efficacy of octreotide in patients with long-standing gastrointestinal bleeding due to acquired angiodysplasia and watermelon stomach, resistant to previous treatments and not suitable for surgery because of old age and/or concomitant disorders. PATIENTS AND METHODS We treated 17 patients (seven had isolated angiodysplasia, seven had multiple upper and lower gastrointestinal angiodysplasia, and three had watermelon stomach) with octreotide (0. 1 mg subcutaneous t.d.s. for 6 months). Six of the patients had liver cirrhosis, one had Glanzmann-type platelet derangement, two had cardiovascular diseases and one had chronic uraemia. RESULTS Octreotide treatment stopped bleeding in 10 patients. A transient improvement was observed in four, who needed subsequent cyclical retreatment to correct low haemoglobin levels. No effect was observed in three, probably due to the severity of the concomitant disorders. CONCLUSIONS Octreotide is a safe drug that may be useful to control the recurrent gastrointestinal bleeding due to acquired angiodysplasia and watermelon stomach, especially in patients who are not candidates for surgery due to old age and/or concomitant disorders.
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Affiliation(s)
- G Nardone
- Cattedra di Gastroenterologia, Università degli Studi 'Federico II', Naples, Italy.
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Tran A, Villeneuve JP, Bilodeau M, Willems B, Marleau D, Fenyves D, Parent R, Pomier-Layrargues G. Treatment of chronic bleeding from gastric antral vascular ectasia (GAVE) with estrogen-progesterone in cirrhotic patients: an open pilot study. Am J Gastroenterol 1999; 94:2909-11. [PMID: 10520843 DOI: 10.1111/j.1572-0241.1999.01436.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Gastric antral vascular ectasia (GAVE) is a rare cause of chronic bleeding in cirrhotic patients. Treatment of GAVE with surgical or nonsurgical portal decompression, beta-blockers, or endoscopic therapy provides disappointing results. In the present study, we evaluated the efficacy of estrogen-progesterone therapy, which has been reported to control chronic bleeding in gastrointestinal vascular malformations, such as Osler-Weber Rendu disease or angiodysplasia, in GAVE-related chronic bleeding. METHODS Six cirrhotic patients who bled chronically from GAVE were included. Three had alcoholic cirrhosis, two cryptogenic cirrhosis, and one primary biliary cirrhosis. Grade 1 esophageal varices were noted in four patients. Bleeding could not be controlled by beta-blockers, and endoscopic therapy was not considered given the extension of the antral vascular lesions. RESULTS Before the start of therapy, transfusion requirements averaged 3.5 units/month over a 1.5-11 month period of observation. Patients were then treated with a combination of ethynil estradiol 30 microg and noretisterone 1.5 mg daily. During follow-up (range 3-12 months), bleeding did not recur in four patients; in one patient, treatment with estrogen progesterone decreased the need for transfusions from 4 units/month to 1.4 unit/month; this patient stopped the treatment inadvertently after 6 months and severe anemia recurred with a need for 4 units of blood in the following month; reintroduction of the treatment resulted in an increase of hemoglobin levels without the need for blood transfusions during the following 4 months. In the last patient, a 5-month treatment did not improve chronic bleeding. CONCLUSIONS The present study suggests that estrogen-progesterone therapy is useful in the treatment of chronic bleeding related to GAVE; however, these findings require confirmation by a controlled trial.
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Affiliation(s)
- A Tran
- Liver Unit, Saint-Luc Hospital, and University of Montreal, Canada
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Spahr L, Villeneuve JP, Dufresne MP, Tassé D, Bui B, Willems B, Fenyves D, Pomier-Layrargues G. Gastric antral vascular ectasia in cirrhotic patients: absence of relation with portal hypertension. Gut 1999; 44:739-42. [PMID: 10205216 PMCID: PMC1727493 DOI: 10.1136/gut.44.5.739] [Citation(s) in RCA: 138] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Portal hypertensive gastropathy and gastric antral vascular ectasia (GAVE) are increasingly recognised as separate entities. The pathogenic role of portal hypertension for the development of GAVE is still controversial. AIMS To evaluate the effects of portal decompression on chronic bleeding related to GAVE in cirrhotic patients. METHODS Eight patients with cirrhosis and chronic blood loss related to GAVE were included. GAVE was defined endoscopically and histologically. RESULTS All patients had severe portal hypertension (mean portocaval gradient (PCG) 26 mm Hg) and chronic low grade bleeding. Seven patients underwent transjugular intrahepatic portosystemic shunt (TIPS) and one had an end to side portacaval shunt. Rebleeding occurred in seven patients. In these, TIPS was found to be occluded after 15 days in one patient; in the other six, the shunt was patent and the PCG was below 12 mm Hg in five. In the responder, PCG was 16 mm Hg. Antrectomy was performed in four non-responders; surgery was uneventful, and they did not rebleed after surgery, but two died 11 and 30 days postoperatively from multiorgan failure. In one patient, TIPS did not control GAVE related bleeding despite a notable decrease in PCG. This patient underwent liver transplantation 14 months after TIPS; two months after transplantation, bleeding had stopped and the endoscopic appearance of the antrum had normalised. CONCLUSIONS Results suggest that GAVE is not directly related to portal hypertension, but is influenced by the presence of liver dysfunction. Antrectomy is a therapeutic option when chronic bleeding becomes a significant problem but carries a risk of postoperative mortality.
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Affiliation(s)
- L Spahr
- Liver Unit, Clinical Research Centre, Campus Saint-Luc, Centre Hospitalier de l'Université de Montréal, Canada
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Abstract
The watermelon stomach syndrome is an increasingly recognized cause of persistent acute or occult gastrointestinal bleeding, typically in elderly women. This disorder often presents with severe iron deficiency anemia, and a variety of associated conditions including autoimmune disease, cirrhosis, achlorhydria, and hypochlorhydria. Diagnosis is made by the characteristic endoscopic appearance of visible linear watermelon-like vascular stripes in the antrum. Histology confirms the vascular nature of this disorder, showing dilated and thrombosed capillaries in the lamina propria, associated with reactive fibromuscular hyperplasia. The optimum treatment of choice is not known. Several treatment options, including surgical antrectomy, and endoscopic photocoagulation with Nd:Yag laser, heater probe therapy, and bipolar electrocautery, have yielded excellent results. Pharmacological agents have also been used to treat selected numbers of patients, most of which comprise a small number of case reports.
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Affiliation(s)
- J E Gretz
- University of Florida, Health Science Center/Jacksonville, USA
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Bourke MJ, Hope RL, Boyd P, Gillespie PE, Ward M, Cowen AE, Williams SJ. Endoscopic laser therapy for watermelon stomach. J Gastroenterol Hepatol 1996; 11:832-4. [PMID: 8889961 DOI: 10.1111/j.1440-1746.1996.tb00088.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Eleven patients (nine females, two males) with anaemia due to acute and chronic gastrointestinal blood loss were found to have gastric antral vascular ectasia (watermelon stomach). Nine patients were transfusion-dependent, receiving a mean of 13.1 units over a mean period of 12.3 months. All patients received neodymium:yttrium-aluminium-garnet laser coagulation with a median of 3.0 treatment sessions. Post-treatment transfusion needs were abolished in six patients and minimal in two patients during a mean follow up of 27.3 months (range 12-60 months). Overall there was a mean reduction in transfusion requirement with treatment from 2.5 units per month to 0.4 units per month (P < 0.02). Mean pretreatment haemoglobin improved from 7.7 to 11.9 g/dL after treatment (P < 0.001). No complications occurred. Laser coagulation is safe and effective treatment for anaemia due to watermelon stomach and should be considered as first line therapy.
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Affiliation(s)
- M J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, New South Wales, Australia
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Tobin RW, Hackman RC, Kimmey MB, Durtschi MB, Hayashi A, Malik R, McDonald MF, McDonald GB. Bleeding from gastric antral vascular ectasia in marrow transplant patients. Gastrointest Endosc 1996; 44:223-9. [PMID: 8885337 DOI: 10.1016/s0016-5107(96)70155-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) leads to blood loss in the disorders of "watermelon stomach" and portal gastropathy, but is not a commonly recognized complication of marrow transplantation. METHODS GAVE was diagnosed when capillary ectasia, focal capillary thromboses, and fibromuscular hyperplasia were identified in antral mucosal biopsy specimens. Marrow transplant patients bleeding from GAVE were reviewed to ascertain common variables in their pretransplant, posttransplant, and bleeding course. RESULTS Six patients developed bleeding due to GAVE. The onset of bleeding was 18 to 94 days after transplant and required an average of 37 U of blood (range, 2 to 130 U). Two patients stopped bleeding after restoration of platelet counts. Two patients had surgical antral resections; both died of multiorgan failure after surgery. Two patients had successful endoscopic laser ablation of vascular lesions and survived. Factors possibly associated with GAVE included male gender, VOD of the liver, oral busulfan as part of the conditioning regimen, and growth factor use after transplant. CONCLUSIONS GAVE was a cause of gastric bleeding in six patients with marrow transplant patients. Restoration of platelet counts and endoscopic laser photocoagulation are the therapies of choice for ongoing bleeding in these patients.
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Affiliation(s)
- R W Tobin
- Gastroenterology/Hepatology Section, Fred Hutchinson Cancer Research Center, Seattle Washington 98104, USA
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Ng I, Lai KC, Ng M. Clinical and histological features of gastric antral vascular ectasia: successful treatment with endoscopic laser therapy. J Gastroenterol Hepatol 1996; 11:270-4. [PMID: 8742925 DOI: 10.1111/j.1440-1746.1996.tb00074.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Gastric antral vascular ectasia is a rare but important cause of chronic gastrointestinal bleeding. We report five patients in whom endoscopic laser therapy successfully controlled repeated blood loss. The patients were elderly (age range: 61-84 years; mean age: 75 years) and three of them were female. Endoscopically, all patients presented with a characteristic antral appearance of either ecstatic vascular 'stripes' radiating out from the pylorus, or multiple cherry-red spots. In all patients, the gastric mucosal biopsy specimens showed dilatation of the capillaries with focal fibrin thrombi and fibromuscular hyperplasia. Marked improvement of both endoscopic and histological features was achieved with endoscopic laser treatment using Nd-YAG laser photocoagulation. Its importance lies in its recognition and successful treatment with endoscopic laser therapy, which offers an effective and relatively safe alternative to surgery, particularly in elderly patients.
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Affiliation(s)
- I Ng
- Department of Pathology, University of Hong Kong, Queen Mary Hospital, Hong Kong
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Yamaoka Y, Konishi H, Kodama T, Kashima K, Yamaguchi T, Imamura M, Ogasawara T, Kizu M. A case of gastric antral vascular ectasia--increase of neuroendocrine cells in the antrum. J Gastroenterol 1995; 30:387-92. [PMID: 7647906 DOI: 10.1007/bf02347516] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We report an 82-year-old woman with severe iron deficiency anemia who was found to have gastric antral vascular ectasia (GAVE). As she required repeated blood transfusion for the anemia and did not respond to various medical treatments, she was referred for antrectomy. The pathogenesis of GAVE is still obscure and may involve many factors. In our patient, immunohistochemical studies of the resected stomach disclosed a marked increase of neuroendocrine cells. The majority of these hyperplastic neuroendocrine cells, furthermore, showed immunoreactivity for 5-hydroxytryptamine (serotonin). These findings suggest that neuroendocrine mediators, serotonin in particular, may have been responsible for the local vasodilation.
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Affiliation(s)
- Y Yamaoka
- Third Department of Internal Medicine, Kyoto Prefectural University of Medicine, Japan
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Saignement gastro-intestinal dû à un estomac en pastèque: traitement par coagulation monopolaire. ACTA ACUST UNITED AC 1995. [DOI: 10.1007/bf02963513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Panés J, Casadevall M, Fernández M, Piqué JM, Bosch J, Casamitjana R, Cirera I, Bombí JA, Terés J, Rodés J. Gastric microcirculatory changes of portal-hypertensive rats can be attenuated by long-term estrogen-progestagen treatment. Hepatology 1994; 20:1261-70. [PMID: 7927261 DOI: 10.1002/hep.1840200525] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
It has been suggested that estrogen-progestagen therapy may be useful in preventing bleeding from gastric angiodysplasia, a vascular lesion similar to that described in portal-hypertensive gastropathy. In this study we assessed the effects of estrogen-progestagen therapy on gastric microcirculation and systemic and splanchnic hemodynamics in portal-hypertensive and sham-operated rats. One week after the surgical procedure (partial portal vein ligation or sham surgery), animals were given an intramuscular injection of a slow-release preparation of estrogen-progestagen or its vehicle. Two weeks later, gastric mucosal blood flow was measured by means of hydrogen gas clearance, a morphometrical analysis of gastric mucosal blood vessels was performed and systemic and splanchnic hemodynamics were evaluated with a radiolabeled-microspheres technique. In portal-hypertensive rats, estrogen-progestagen therapy induced a significant reduction in gastric mucosal blood flow, number of blood vessels and relative area of vessels. Similar changes, although of lesser magnitude, were achieved with estrogen or progestagen given separately and with the low dose of combined estrogen-progestagen. Estrogen-progestagen treatment also induced significant reductions in portal pressure and porto-collateral resistance without changing systemic or splanchnic hemodynamics. In contrast, estrogen-progestagen treatment did not induce changes in any of the parameters studied in sham-operated rats. We conclude that long-term estrogen-progestagen therapy reduces the gastric hyperemia, increased mucosal vessel density and portal pressure in portal-hypertensive rats.
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Affiliation(s)
- J Panés
- Gastroenterology Department, Hospital Clínic, Barcelona, Spain
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