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Fang Z, Zhu J, Fang Z, Hu Q, Yang L. A delayed gastric antral vascular ectasia: A case report and literature review. Medicine (Baltimore) 2024; 103:e40831. [PMID: 39969353 PMCID: PMC11688045 DOI: 10.1097/md.0000000000040831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Accepted: 11/18/2024] [Indexed: 02/20/2025] Open
Abstract
RATIONALE Gastric antral vascular ectasia (GAVE) is a rare cause of gastrointestinal bleeding. It presents challenges in both diagnosis and treatment. PATIENT CONCERN We reported a female patient who was initially misdiagnosed with hemorrhage of the digestive tract. She was treated with medication for 4 months, but her hemoglobin levels still declined without blood transfusion. DIAGNOSIS Her diagnosis was GAVE after an endoscopic examination. INTERVENTIONS She was treated with an endoscopic argon plasma coagulation treatment, an endoscopic band ligation treatment, medication, and traditional Chinese medicine. OUTCOMES This case was followed up for 6 months and her hemoglobin levels were above 9 g/dL. LESSONS A combination treatment of endoscopic and medication treatment will be a good choice of GAVE. More comprehensive understanding of GAVE will be build up with the developments of new technologies and methods.
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Affiliation(s)
- Zheke Fang
- Department of Rehabilitation, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang Province, China
- Zhejiang Academy of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
| | - Jiajie Zhu
- Zhejiang Academy of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
- Department of Gastroenterology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Zheng Fang
- Zhejiang Academy of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
- Department of Gastroenterology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Qiang Hu
- Zhejiang Academy of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
- Department of General Surgery, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang Province, China
| | - Liangjun Yang
- Zhejiang Academy of Traditional Chinese Medicine, Hangzhou, Zhejiang Province, China
- Department of Gastroenterology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang Province, China
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Choi W, Lauwers GY, Slavik T. Inflammatory disorders of the stomach. MORSON AND DAWSON'S GASTROINTESTINAL PATHOLOGY 2024:135-194. [DOI: 10.1002/9781119423195.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
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Stancu G, Iliescu EL. Mucosal Healing of Gastric Antral Vascular Ectasia (Watermelon Stomach) After Treatment With Azathioprine. Cureus 2024; 16:e70490. [PMID: 39479149 PMCID: PMC11522947 DOI: 10.7759/cureus.70490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2024] [Indexed: 11/02/2024] Open
Abstract
Gastric antral vascular ectasia (GAVE), commonly known as "watermelon stomach," is characterized by parallel red stripes resembling watermelon stripes on endoscopic examination and is an uncommon but significant cause of chronic gastrointestinal bleeding, often associated with systemic diseases such as autoimmune conditions, liver cirrhosis, chronic renal insufficiency, and cardiovascular disease. Various therapeutic approaches have been introduced for GAVE treatment, including medical, endoscopic, and surgical interventions. We report a case of a 60-year-old man with a prior history of GAVE who developed melena and symptomatic severe anemia. Initial esophagogastroduodenoscopy (EGD) demonstrated oozing antral GAVE. The patient required weekly blood transfusions. In this article, we explored the safety and efficacy of azathioprine treatment for GAVE. We administered 100 mg (oral) of azathioprine once daily and evaluated the patient monthly for four months. After two months, the endoscopy examination results showed visible macroscopic improvement, and after four months, the lesions were healed. The healing process was complete with normal mucosa restored. After two months, there wasn't any need for blood transfusions or iron therapy. We present for the first time the endoscopic healing process of GAVE under azathioprine treatment confirming that the cause of GAVE is autoimmune. Further research is needed to optimize therapeutic strategies and improve patient outcomes.
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Affiliation(s)
- George Stancu
- Gastroenterology and Hepatology, Valahia Medical Center, Ploiesti, ROU
- Department of Internal Medicine, Fundeni Clinical Institute, Bucharest, ROU
- Internal Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Elena Laura Iliescu
- Department of Internal Medicine II, Fundeni Clinical Institute, Bucharest, ROU
- Internal Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
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Kwon HJ, Lee SH, Cho JH. Influences of etiology and endoscopic appearance on the long-term outcomes of gastric antral vascular ectasia. World J Clin Cases 2022; 10:6050-6059. [PMID: 35949841 PMCID: PMC9254169 DOI: 10.12998/wjcc.v10.i18.6050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/31/2022] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) has diverse associations and presumed causes, which include liver cirrhosis, chronic kidney disease, and autoimmune disease. This heterogeneity of underlying disorders suggests that the pathogenesis of GAVE may be variable.
AIM To compare the clinical features and long-term outcomes of GAVE according to endoscopic patterns and etiologies.
METHODS The medical records and endoscopic images of 23 consecutive patients diagnosed with GAVE by endoscopy at Yeungnam University Hospital from January 2006 to December 2020 were retrospectively reviewed. Patients were allocated to cirrhosis (16 patients) and non-cirrhosis groups (7 patients). GAVE subtypes, as determined by endoscopy, were categorized as punctate (a diffuse, honeycomb-like appearance, 17 patients) or striped (a linear, watermelon-like appearance, 6 patients).
RESULTS All GAVE patients with cirrhosis (16/16, 100%) had a punctate pattern by endoscopy, whereas the majority of patients (6/7, 85.7%) without cirrhosis had a striped pattern (P < 0.001). Overt GAVE bleeding (10/23, 43%) was significantly more common in the non-cirrhosis group than in the cirrhosis group (6/7, 85.7% vs 4/16, 25.0%; P = 0.019), and more common in the striped group than in the punctate group (5/6, 83.3% vs 5/17, 29.4%; P = 0.052). However, mean numbers of admissions due to GAVE bleeding and argon plasma coagulation (APC) sessions to address overt bleeding were similar in the cirrhosis and non-cirrhosis groups and in the punctate and striped groups. All patients with GAVE bleeding were successfully treated by APC, and no patient died from GAVE-related blood loss during a median follow-up of 24 mo.
CONCLUSION Punctate-type GAVE is strongly associated with liver cirrhosis, and GAVE patients without cirrhosis tend to be more prone to overt bleeding. However, the presence of cirrhosis and endoscopic patterns did not influence long-term clinical courses or outcomes in cases of overt bleeding.
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Affiliation(s)
- Hyo Jin Kwon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
| | - Si Hyung Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
| | - Joon Hyun Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
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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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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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Fouad M, Khalaf Fath-Elbab H, Mostafa AM, Moness HM, Adel NM, Ahmed E. Gastric antral vascular ectasia in hepatitis C virus related liver cirrhosis: Fetching for predictors. JGH OPEN 2021; 5:923-928. [PMID: 34386601 PMCID: PMC8341197 DOI: 10.1002/jgh3.12607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 06/19/2021] [Accepted: 06/22/2021] [Indexed: 11/08/2022]
Abstract
Background and Aim Gastric antral vascular ectasia (GAVE) is observed in patients with liver cirrhosis and portal hypertension. The exact pathophysiologic mechanism that underlies this condition is unknown. In our study, we estimate the prevalence of GAVE in hepatitis C virus (HCV) cirrhosis and attempted to determine if any of the hepatocellular manifestations, liver functions, serum gastrin, abdominal ultrasound and endoscopic picture have a relation to, or could predict, the occurrence of GAVE in cirrhotic patients. Methods This study includes 500 HCV‐related liver cirrhosis patients. According to endoscopic assessment, we detected 30 patients with GAVE (Group 2). From the 470 patients without GAVE, we randomly selected 120 patients (Group 1), to avoid statistical bias, for comparison with Group 2. Comparison included clinical manifestations, laboratory findings, serum gastrin, ultrasound findings, and endoscopic findings (esophageal and/or gastric varices and gastropathy). Results The percentage of GAVE in HCV‐related liver cirrhosis is 0.06%. We can predict GAVE by platelets, palmer erythema, diabetes mellitus (DM), marked ascites > with area under the curve of 0.67, 75.5, 0.62, and 0.40%, and accuracy of 82.5, 72, 70.7, and 79.3%, respectively. There was no correlation found between occurrence of GAVE and endoscopic findings. Also, there was no correlation found between occurrence of GAVE and serum gastrin levels, which reflect another pathophysiology, and we found no statistically significant correlation with GAVE. Conclusions Palmer erythema, low platelets, DM, and ascites might help in the prediction of GAVE. GAVE is not linked to the presence, type or grade of varices, and gastropathy.
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Affiliation(s)
- Magdy Fouad
- Gastroenterology and Hepatology Unit, Department of Tropical Medicine Faculty of Medicine - Minia University Minia Egypt
| | - Hanaa Khalaf Fath-Elbab
- Gastroenterology and Hepatology Unit, Department of Tropical Medicine Faculty of Medicine - Minia University Minia Egypt
| | - Alaa Mohamed Mostafa
- Gastroenterology and Hepatology Unit, Department of Tropical Medicine Faculty of Medicine - Minia University Minia Egypt
| | - Hend M Moness
- Department of Clinical Pathology Faculty of Medicine - Minia University Minia Egypt
| | | | - Elham Ahmed
- Department of Internal Medicine Faculty of Medicine - Minia University Minia Egypt
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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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Ali SE, Benrajab KM, Cruz ACD. Outcome of gastric antral vascular ectasia and related anemia after orthotopic liver transplantation. World J Hepatol 2020; 12:1067-1075. [PMID: 33312430 PMCID: PMC7701976 DOI: 10.4254/wjh.v12.i11.1067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/04/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) is a significant complication of cirrhosis. Numerous medical, surgical, and endoscopic treatment modalities have been proposed with varied satisfactory results. In a few small studies, GAVE and associated anemia have resolved after orthotopic liver transplantation (OLT).
AIM To assess the impact of OLT on the resolution of GAVE and related anemia.
METHODS We retrospectively reviewed clinical records of adult patients with GAVE who underwent OLT between September 2012 and September 2019. Demographics and other relevant clinical findings were collected, including hemoglobin levels and upper endoscopy findings before and after OLT. The primary outcome was the resolution of GAVE and its related anemia after OLT.
RESULTS Sixteen patients were identified. Mean pre-OLT Hgb was 7.7 g/dL and mean 12 mo post-OLT Hgb was 11.9 g/dL, (P = 0.001). Anemia improved (defined as Hgb increased by 2g) in 87.5% of patients within 6 to 12 mo after OLT and resolved completely in half of the patients. Post-OLT esophagogastroduodenoscopy was performed in 10 patients, and GAVE was found to have resolved entirely in 6 of those patients (60%).
CONCLUSION Although GAVE and associated anemia completely resolved in the majority of our patients after OLT, GAVE persisted in a few patients after transplant. Further studies in a large group of patients are necessary to understand the causality of disease and to better understand the factors associated with the persistence of GAVE post-transplant.
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Affiliation(s)
- Saad Emhmed Ali
- Division of Hospital Medicine, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Karim M Benrajab
- Division of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Anna Christina Dela Cruz
- Division of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY 40536, United States
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Cleac’h AL, Villeneuve JP, Sylvestre MP, Huard G, Giard JM, Ditisheim S. Gastric antral vascular ectasia is more frequent in patients with non-alcoholic steatohepatitis-induced cirrhosis. CANADIAN LIVER JOURNAL 2019; 2:84-90. [PMID: 35990220 PMCID: PMC9202753 DOI: 10.3138/canlivj.2018-0021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/16/2018] [Indexed: 11/24/2023]
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) is an uncommon cause of occult gastrointestinal (GI) bleeding. Based on clinical observations, we hypothesized that GAVE was more common in patients with non-alcoholic steatohepatitis (NASH) cirrhosis. METHODS We performed this retrospective study at Centre Hospitalier de l'Université de Montréal (CHUM). We included all cirrhotic patients who had undergone an esophagogastroduodenoscopy (EGD) between 2009 and 2011. GAVE was diagnosed based on a typical endoscopic appearance. NASH cirrhosis was diagnosed in patients with a metabolic syndrome after excluding other causes of liver disease. GAVE was considered symptomatic if it required treatment. RESULTS We included 855 cirrhotic patients in the study. The median age was 58 (range 19-88) years. The etiology of cirrhosis was as follows: NASH in 18% (n = 154), autoimmune diseases in 15.1% (n = 129), hepatitis B virus (HBV) in 6.3% (n = 54), hepatitis C virus (HCV) in 19.4% (n = 166), alcohol in 25.7% (n = 220), alcohol plus HCV in 7.8% (n = 67), cryptogenic in 2.8% (n = 24), and other etiologies in 4.8% (n = 41). GAVE was more frequently observed among patients with NASH cirrhosis than in cirrhosis of other etiologies (29.2% vs. 9.4%, respectively; p < 0.001). In multivariate analysis, NASH was strongly associated with GAVE with an odds ratio (OR) of 3.73 (95% CI 2.36 to 5.90, p < 0.001), and the association was stronger with symptomatic GAVE (OR 5.77, 95% CI 2.93 to 11.38). CONCLUSIONS NASH cirrhosis is a major risk factor for GAVE and symptomatic GAVE.
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Affiliation(s)
- Aline Le Cleac’h
- Division of Hepatology, Department of Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, Québec
| | - Jean-Pierre Villeneuve
- Division of Hepatology, Department of Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, Québec
| | - Marie-Pierre Sylvestre
- Department of Social and Preventive Medicine, Université de Montréal & Centre de recherche du Centre Hospitalier de l’Université de Montréal, Montréal, Québec
| | - Geneviève Huard
- Division of Hepatology, Department of Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, Québec
| | - Jeanne-Marie Giard
- Division of Hepatology, Department of Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, Québec
| | - Saskia Ditisheim
- Division of Hepatology, Department of Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, Québec
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Magee C, Lipman G, Alzoubaidi D, Everson M, Sweis R, Banks M, Graham D, Gordon C, Lovat L, Murray C, Haidry R. Radiofrequency ablation for patients with refractory symptomatic anaemia secondary to gastric antral vascular ectasia. United European Gastroenterol J 2019; 7:217-224. [PMID: 31080606 PMCID: PMC6498795 DOI: 10.1177/2050640618814659] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/28/2018] [Indexed: 12/12/2022] Open
Abstract
Background Gastric antral vascular ectasia (GAVE) is a rare cause of gastrointestinal bleeding, often causing iron deficiency anaemia. Previous studies have looked at the management of this with argon plasma coagulation, laser therapy and endoscopic band ligation. Methods This was a single-centre prospective study to evaluate the efficacy and safety of radiofrequency ablation (RFA) in patients with GAVE with persistent anaemia refractory to at least one session of first-line endoscopic therapy. Patients were treated with a through-the-scope (TTS) radiofrequency catheter at two endoscopic sessions six weeks apart. The primary outcome was change in haemoglobin at six months posttreatment. The secondary outcomes were reduction in blood or iron requirements, endoscopic surface area regression and complications. Results Twenty patients were treated. The mean change in haemoglobin at six months was +12.6 g/l (95% confidence interval 11.7-24.3 g/l), paired t test p < 0.001. At six months, three of 14 individuals who had required blood transfusions had ongoing blood transfusions and five of 17 who had required iron had ongoing iron needs. Surface area regression was scored as 74% ± 25% but no correlation was seen between this and other outcomes. Three of 20 patients experienced pain which was managed with oral analgesia. Of the 14 patients who had reached 12-month follow-up, three required retreatment (21%). Discussion This small study suggests that RFA is a safe and effective treatment for GAVE. Our study uses the TTS catheter compared to other studies, and demonstrates prolonged improvement in haemoglobin and reduction in blood and iron requirements with a novel assessment of surface area regression.
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Affiliation(s)
- Cormac Magee
- University College London Hospital, London, UK
- Centre for Obesity Research, University College London, London, UK
| | - Gideon Lipman
- University College London Hospital, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Durayd Alzoubaidi
- University College London Hospital, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Martin Everson
- University College London Hospital, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Rami Sweis
- University College London Hospital, London, UK
| | | | | | - Charles Gordon
- Royal Bournemouth and Christchurch Hospital, Bournemouth, UK
| | - Laurence Lovat
- University College London Hospital, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | - Rehan Haidry
- University College London Hospital, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
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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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Rimševičius L, Galkauskas D, Lavinskas J, Šestelinska E, Mačionienė E, Laučytė-Cibulskienė A, Rėkutė S, Miglinas M. Gastric antral vascular ectasia should not be overlooked in erythropoietin resistance: a series of case reports. Acta Med Litu 2018; 25:219-225. [PMID: 31308827 DOI: 10.6001/actamedica.v25i4.3932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Gastric antral vascular ectasia (GAVE) is currently recognized as an important cause of upper gastrointestinal (GI) haemorrhage, being responsible for about 4% of non-variceal upper GI haemorrhages and typically presents in middle-aged females. GAVE, also called "watermelon stomach", is diagnosed through esophagogastroduodenoscopy and is characterized by the presence of visible columns of red tortuous enlarged vessels along the longitudinal folds of the antrum. The pathogenesis is still obscure and many hypotheses have been proposed such as mechanical stress, humoral and autoimmune factors. In the last two decades, numerous therapeutic strategies have been proposed, including surgical, endoscopic, and medical choices, yet successful treatment of GAVE continues to be a challenge. 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. The actual GAVE prevalence in patients with end-stage renal disease (ESRD) is not clear, yet in difficult cases it should be considered as a cause of erythropoietin resistance. Case presentation We report four clinical cases of GAVE syndrome patients diagnosed with stage 4 to 5 chronic kidney disease. All patients presented with anaemia and GI haemorrhage, the origin of which turned out to be GAVE syndrome. Conclusions GAVE syndrome is a serious condition in ESRD patients, especially in those presenting with treatment-refractory anaemia. Realization of its aetiology and characteristics is essential to suspect, diagnose, and treat gastric ectasia. Only proper diagnosis and well-timed disease treatment can significantly improve a patient's medical condition and future prognosis.
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Affiliation(s)
| | | | | | | | | | | | - Skirmantė Rėkutė
- Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Marius Miglinas
- Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
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Allamneni C, Alkurdi B, Naseemuddin R, McGuire BM, Shoreibah MG, Eckhoff DE, Peter S. Orthotopic liver transplantation changes the course of gastric antral vascular ectasia: a case series from a transplant center. Eur J Gastroenterol Hepatol 2017; 29:973-976. [PMID: 28520574 DOI: 10.1097/meg.0000000000000908] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIM Gastric antral vascular ectasia (GAVE) is an important cause of upper gastrointestinal bleeding and anemia in patients with cirrhosis. The aim of our study was to evaluate the effect of orthotopic liver transplantation (OLT) on GAVE and associated anemia. PATIENTS AND METHODS We performed a chart review and identified all cirrhotic patients with GAVE who underwent OLT at the University Of Alabama at Birmingham between 2005 and 2013. Population's demographics, etiology of cirrhosis, comorbidities, presentation and treatment modalities of GAVE, endoscopic and histopathologic reports, hemoglobin values before and after transplant, and immunosuppressive regimens were collected. RESULTS Twelve patients were identified, mean age 52.4±4.4 years; seven were men (58.3%); 11 (91.7%) were White; and 6 of 12 patients had biopsy-proven GAVE. The most common etiology of cirrhosis in the cohort was chronic hepatitis C and obesity was the most common chronic condition in 50 and 83.3%, respectively. Anemia resolution was observed in 9/12 (75%) patients who underwent OLT with an increase in hemoglobin from 8.1±2.4 (5.7-13.1) before transplant to 12.0±1.4 (10-15) after transplant (P<0.0001). Esophagogastroduodenoscopy after transplant was performed in all 12 (100%) patients. The mean time between transplant and post-OLT esophagogastroduodenoscopy was 13.8±18.28 (2-57) months; complete resolution of GAVE was observed in 10 (83.3%) patients, with resolving GAVE in one (8.3%) patient. CONCLUSION GAVE is an important cause of anemia and upper gastrointestinal bleeding in patients with liver cirrhosis. Our findings show that liver transplantation can resolve GAVE and related anemia.
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Affiliation(s)
- Chaitanya Allamneni
- aDepartment of Medicine, Division of Gastroenterology and Hepatology bDepartment of Surgery, Division of Transplant Surgery cDepartment of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Nakade Y, Ozeki T, Kanamori H, Inoue T, Yamamoto T, Kobayashi Y, Ishii N, Ohashi T, Ito K, Yoneda M. A Case of Gastric Antral Vascular Ectasia Which Was Aggravated by Acid Reducer. Case Rep Gastroenterol 2017; 11:64-71. [PMID: 28611555 PMCID: PMC5465652 DOI: 10.1159/000455967] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 01/03/2017] [Indexed: 12/22/2022] Open
Abstract
Gastric antral vascular ectasia (GAVE) is known to be characterized by red patches or spots in a diffuse or linear array in the antrum of the stomach. The precise etiology of GAVE remains to be elucidated. Argon plasma laser coagulation (APC) has been used to control oozing from GAVE; however, there is no satisfactory long-term effect of APC in the control of oozing from GAVE. An acid reducer is used after APC because even physiological acid exposure might delay post-APC ulcer healing. We describe the case of a patient who had used an acid reducer and experienced repeated gastrointestinal hemorrhage due to GAVE. After ceasing to administer the acid reducer, incidences of hospitalization due to oozing from GAVE stopped. After the administration of the acid reducer was restarted, the patient had tarry stool, and diffuse oozing of blood was seen again. We report a first case of GAVE which was aggravated by acid reducer.
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Affiliation(s)
- Yukiomi Nakade
- aDivision of Gastroenterology, Department of Internal Medicine, Aichi Medical University, Nagakute, Japan
| | - Tomonori Ozeki
- bDivision of Gastroenterology, Nagoya City West Medical Center, Nagoya, Japan
| | - Hiroyuki Kanamori
- aDivision of Gastroenterology, Department of Internal Medicine, Aichi Medical University, Nagakute, Japan
| | - Tadahisa Inoue
- aDivision of Gastroenterology, Department of Internal Medicine, Aichi Medical University, Nagakute, Japan
| | - Takaya Yamamoto
- aDivision of Gastroenterology, Department of Internal Medicine, Aichi Medical University, Nagakute, Japan
| | - Yuji Kobayashi
- aDivision of Gastroenterology, Department of Internal Medicine, Aichi Medical University, Nagakute, Japan
| | - Norimitsu Ishii
- aDivision of Gastroenterology, Department of Internal Medicine, Aichi Medical University, Nagakute, Japan
| | - Tomohiko Ohashi
- aDivision of Gastroenterology, Department of Internal Medicine, Aichi Medical University, Nagakute, Japan
| | - Kiyoaki Ito
- aDivision of Gastroenterology, Department of Internal Medicine, Aichi Medical University, Nagakute, Japan
| | - Masashi Yoneda
- aDivision of Gastroenterology, Department of Internal Medicine, Aichi Medical University, Nagakute, Japan
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Smith E, Tekola B, Patrie J, Cornella S, Caldwell S. Clinical Characterization of Gastric Antral Vascular Ectasia: A Potential Manifestation of the Metabolic Syndrome. Am J Med 2016; 129:1329.e19-1329.e23. [PMID: 27476085 DOI: 10.1016/j.amjmed.2016.07.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 07/05/2016] [Accepted: 07/05/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Gastric antral vascular ectasia is a relatively common endoscopic finding. Past studies have shown an association of gastric antral vascular ectasia with cirrhosis and autoimmune disorders. We aimed to re-examine these associations and to investigate a possible association of gastric antral vascular ectasia with features of the metabolic syndrome. METHODS There were 135 patients with a diagnosis of gastric antral vascular ectasia from years 1995-2013 seen at the University of Virginia who were identified from a clinical data repository and age and sex matched to a cohort of patients without gastric antral vascular ectasia undergoing endoscopy within the same time frame as the index cases. The groups were compared for comorbidities including autoimmune disease, cirrhosis, vascular disease, body mass index (BMI), diabetes mellitus, and cirrhosis due to nonalcoholic steatohepatitis. RESULTS Sixty-four percent of gastric antral vascular ectasia patients were cirrhotic, compared with 14% of controls (P <.001). Vascular disease was more common in the gastric antral vascular ectasia cohort (57% vs 36%; P <.001). The mean BMI was also higher in the gastric antral vascular ectasia cohort (33.7 kg/m2 vs 28.8 kg/m2; P <.001). Diabetes mellitus and nonalcoholic steatohepatitis cirrhosis were more frequently observed in gastric antral vascular ectasia subjects (64% vs 29% in controls [P <.001] and 28% vs 2% [P <.001], respectively). There was not an increased prevalence of autoimmune disease in gastric antral vascular ectasia patients vs controls (15% vs 13%; P = .861). CONCLUSION These results confirm the association of gastric antral vascular ectasia with underlying cirrhosis and revealed a significant correlation of gastric antral vascular ectasia with features of metabolic syndrome such as diabetes, BMI, vascular disease, and nonalcoholic steatohepatitis cirrhosis. The pathophysiology of gastric antral vascular ectasia remains uncertain, but we speculate that it may be a manifestation of the metabolic syndrome.
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Affiliation(s)
- Elliot Smith
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville
| | - Bezawit Tekola
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville
| | - James Patrie
- Division of Public Health, University of Virginia, Charlottesville
| | - Scott Cornella
- Division of Internal Medicine, University of Virginia, Charlottesville
| | - Stephen Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville.
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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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Wang J, Stine JG, Cornella SL, Argo CK, Cohn SM. Patients with Gastric Antral Vascular Ectasia (GAVE) Are at a Higher Risk of Gastrointestinal Bleeding in the Absence of Cirrhosis. J Clin Transl Hepatol 2015; 3:254-9. [PMID: 26807380 PMCID: PMC4721892 DOI: 10.14218/jcth.2015.00031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 10/09/2015] [Accepted: 10/11/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Gastric antral vascular ectasia (GAVE) is commonly found in patients with cirrhosis, but it is also associated with other diseases in the absence of cirrhosis. Whether GAVE confers a different severity of gastrointestinal (GI) bleeding between patients with and without cirrhosis remains unknown. We aim to examine whether there is a difference in clinically significant GI bleeding due to GAVE in patients with or without cirrhosis. METHODS This is a retrospective case-control study of patients who were diagnosed with GAVE between January 2000 and June 2014. Patients were categorized into cirrhosis and noncirrhosis groups, and those with an additional GI bleeding source were excluded. Univariate comparisons and multivariable models were constructed using logistic regression. RESULTS In total, 110 patients diagnosed with GAVE on esophagogastroduodenoscopy (EGD) were included in our analysis; 84 patients had cirrhosis (76.4%) and 26 (23.6%) did not. Active GI bleeding was more prevalent in patients without cirrhosis (63.4% vs. 32.1%, p=0.003) despite similar indications for EGD, and endoscopic treatment with argon plasma coagulation (APC) was required more often in this group, approaching statistical significance (27% vs. 10.7%, p=0.056). There was no difference in bleeding severity, as evidenced by similar re-bleeding rates, surgery, or death attributed to uncontrolled bleeding. The strongest independent risk factor for GI bleeding was the absence of cirrhosis (odds ratio (OR): 5.151 (95% confidence interval (CI): 1.08-24.48, p=0.039). CONCLUSIONS Patients with GAVE in the absence of cirrhosis are at higher risk for active GI bleeding and require more frequent endoscopic treatment than similar patients with cirrhosis. It may be worthwhile to treat GAVE in this population even in the absence of active bleeding.
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Affiliation(s)
- Jennifer Wang
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Jonathan G. Stine
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
- Correspondence to: Jonathan G Stine, Division of Gastroenterology and Hepatology, JPA and Lee Street, MSB2145, PO Box 800708, University of Virginia, Charlottesville, VA 22908-0708, USA. Tel: +1-434-243-7741, Fax: +1-434-244-7529, E-mail:
| | - Scott L. Cornella
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Curtis K. Argo
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Steven M. Cohn
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
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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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20
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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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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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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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Effect of experimentally induced portal hypertension on the fundic mucosa of adult male albino rats and the possible protective role of quercetin supplementation. ACTA ACUST UNITED AC 2013. [DOI: 10.1097/01.ehx.0000425561.09044.f9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [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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Sato T, Yamazaki K, Akaike J. Endoscopic band ligation versus argon plasma coagulation for gastric antral vascular ectasia associated with liver diseases. Dig Endosc 2012; 24:237-42. [PMID: 22725108 DOI: 10.1111/j.1443-1661.2011.01221.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIM The aim of the present study was to evaluate the clinicopathological features and the efficacy of endoscopic treatments in treating gastric antral vascular ectasia (GAVE) in association with liver diseases. METHODS Thirty-four patients with the characteristic endoscopic findings of GAVE were enrolled. Endoscopic treatments were carried out for all 34 patients, including argon plasma coagulation (APC) in 22 patients and endoscopic band ligation (EBL) in 12 patients. RESULTS All 34 patients had iron-deficiency anemia and 21 patients also had a history of tarry stools. The underlying pathologies of chronic liver diseases were liver cirrhosis in 26 patients, liver cirrhosis associated with hepatocellular carcinoma in six, and idiopathic portal hypertension in two. The liver function was classified by Child-Pugh classification: class A (n=6), class B (n=21), and class C (n=7). Antral motility was frequent and intense in all 34 GAVE patients. In the 22 patients who received APC, endoscopies revealed the recurrence of GAVE in 15 patients requiring further treatment by APC (recurrence rate, 68.2%). Seven patients died during the follow-up period, including two cases with bleeding-related deaths. In the 12 patients who received EBL, endoscopies revealed the recurrence of GAVE in one patient requiring further treatment by EBL (recurrence rate, 8.3%). Two patients died during the follow-up period, neither were bleeding-related deaths. CONCLUSIONS The results suggest that GAVE is related to severe liver damage and portal hypertension. APC has a high recurrence rate of GAVE in the medium term after treatment. EBL may be useful as a treatment for GAVE.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan.
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Iguchi A, James Kazama J, Komatsu M, Kaneko Y, Iino N, Goto S, Narita I. Three cases of gastric antral vascular ectasia in chronic renal failure. CASE REPORTS IN NEPHROLOGY AND UROLOGY 2011. [PMID: 23197946 PMCID: PMC3485665 DOI: 10.1159/000332832] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Gastric antral vascular ectasia (GAVE) is currently recognized as an important cause of gastrointestinal bleeding. Chronic kidney disease (CKD) is associated with a high incidence of GAVE. We report 3 patients with CKD who presented with severe anemia and were diagnosed with GAVE; they were resistant to endoscopic argon plasma coagulation. However, remission of anemia and improvement in GAVE lesions were observed after the initiation of hemodialysis. The pathogenesis of GAVE remains largely unknown, but mechanical stress of the antrum could play an important role. This stress may be reduced by hemodialysis through improvement of uremia-associated gastrointestinal symptoms. Therefore, the initiation of hemodialysis might be effective for intractable GAVE in CKD patients.
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Affiliation(s)
- Akira Iguchi
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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27
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Laparoscopic Surgical Treatment for Refractory Gastric Antral Vascular Ectasia. Surg Laparosc Endosc Percutan Tech 2009; 19:e189-93. [DOI: 10.1097/sle.0b013e3181bb5a19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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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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29
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IKEDA M, INOKI K, HAYASHI N, YAMAMOTO K, MASUZAWA M, TAKEDA M. Successful Endoscopic Treatment of Diffuse Antral Vascular Ectasia and Early Gastric Carcinoma in an Aged Patient. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1995.tb00131.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Masahiro IKEDA
- *Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Ken INOKI
- *Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Nobuhiko HAYASHI
- *Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Keiji YAMAMOTO
- *Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Manabu MASUZAWA
- *Department of Gastroenterology, Osaka National Hospital, Osaka, Japan
| | - Masashi TAKEDA
- **Department of Clinical Laboratory, Osaka National Hospital, Osaka, Japan
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Abstract
The discovery of Helicobacter pylori and its intimate role in the development of the most common form of chronic gastritis has elicited a much-needed interest in non-neoplastic gastric pathology. This has been paralleled by an increase in upper endoscopic examinations, which allow recognition of novel patterns and distribution of mucosal injury. Numerous attempts at classification have been made, most based on the acuteness or chronicity of gastric mucosal injury. In this review, we will not offer a new classification but present a detailed description of the major clinicopathological entities, based either on the salient morphological features or the underlying aetiologies, i.e. iatrogenic, autoimmune, vascular or idiopathic.
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Affiliation(s)
- A Srivastava
- Department of Pathology, Dartmouth Hitchcock Medical Center and Dartmouth Medical School, Lebanon, NH, USA
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31
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Blanc P, Phelip JM, Bertolino JG, Atger J, Roblin X. L’estomac pastèque : une cause rare d’anémie ferriprive, de traitement chirurgical ; un nouveau cas et revue de la littérature. ACTA ACUST UNITED AC 2003; 128:462-4. [PMID: 14559197 DOI: 10.1016/s0003-3944(03)00175-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The authors report a new case of water-melon stomach, without portal hypertension, and responsible for a iron deficiency anemia cured by antrectomy. Water-melon stomach is a particular form of gastric antral vascular ectasia, characterized by a specific and striking endoscopic aspect. The diagnostic, histologic, pathogenic and therapeutic aspects are reviewed.
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Affiliation(s)
- P Blanc
- Service chirurgie viscérale, CH Gap, 1, place Auguste-Muret, 05000 Gap, France.
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32
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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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33
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Soykan I, Toruner M, Idilman R, Ozden A. Reversal of iron deficiency anemia in a patient with gastric antral vascular ectasia treated with cyproheptadine. J Clin Gastroenterol 2003; 36:183-4. [PMID: 12544207 DOI: 10.1097/00004836-200302000-00021] [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: 12/09/2022]
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34
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Abstract
Portal hypertensive gastropathy (PHG), a term used to describe the endoscopic appearance of gastric mucosa with a characteristic mosaic-like pattern with or without red spots, is a common finding in patients with portal hypertension. Current classification systems that describe the severity of PHG have many limitations, but it appears that simple grading systems have better inter- and intraobserver agreement. The wide variation in the reported prevalence of PHG is probably related to selection bias, absence of uniform criteria and classification, and more importantly, the differences in inter- and intraobserver variation. Pathogenesis of PHG is not clearly defined, but there is a very close relationship between portal hypertension and development of PHG. GAVE is a separate entity from PHG, but patients with severe PHG may have a GAVE-like appearance in the gastric antrum. Acute bleeding from PHG, seen usually in the presence of severe PHG, is often mild and self-limiting. Currently, the only treatment that could be recommended for prophylaxis of bleeding from PHG is nonselective B-blockers.
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Affiliation(s)
- Paul J Thuluvath
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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35
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Abstract
This is the first reported case of rectal vascular ectasia in association with gastric antral vascular ectasia (watermelon stomach). The patient, a 39-year-old woman with systemic sclerosis, reported chronic gastrointestinal blood loss and iron deficiency anemia. She had aperistalsis of the distal esophagus, decreased lower esophageal sphincter pressure leading to severe gastroesophageal reflux, and dysmotility of the small intestine. Diagnosis was made by endoscopic appearance of visible linear watermelon-like vascular stripes in the gastric antrum and rectum. Histology confirmed the vascular nature of this disorder, showing dilated and thrombosed capillaries in the lamina propria. Gastric biopsy showed associated fibromuscular hyperplasia in the lamina propria. However, the colonic biopsy showed only focal hyalinization in the lamina propria. The patient was successfully treated using endoscopic bipolar electrocautery. Watermelon stomach has previously been described in association with systemic sclerosis. Based on the histopathologic similarity between rectal vascular ectasia, gastric antral vascular ectasia, and systemic sclerosis, we suggest that the rectal vascular lesion may represent a component of the gastrointestinal manifestations of systemic sclerosis.
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Affiliation(s)
- D Singh
- Department of Internal Medicine, Akron General Medical Center, Akron, Ohio 44307, USA
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36
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Ito M, Uchida Y, Kamano S, Kawabata H, Nishioka M. Clinical comparisons between two subsets of gastric antral vascular ectasia. Gastrointest Endosc 2001; 53:764-70. [PMID: 11375585 DOI: 10.1067/mge.2001.113922] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The lesions of gastric antral vascular ectasia take two endoscopic forms, diffuse red spots and red stripes. In addition, they are often associated with cirrhosis. The main aim of the present retrospective study was to determine whether differences in endoscopic appearance and presence or absence of cirrhosis have relationships to clinical features and course. METHODS Gastric antral vascular ectasia in 30 patients was classified into 2 endoscopic subtypes, punctate type (21 patients) and striped type (8 patients); only 1 patient could not be categorized to either type. The 30 patients were divided into groups based on the presence (25) or absence (5) of cirrhosis. RESULTS All patients with punctate-type vascular ectasias had cirrhosis, whereas only 38% of patients with the striped type had cirrhosis. All patients without cirrhosis had the striped pattern. For patients with the 2 endoscopic types as well as those with and without cirrhosis, the outcomes of endoscopic treatment were similar. CONCLUSIONS The findings of the present study suggest that cirrhosis is strongly associated with the development of punctate-type vascular ectasias. The endoscopic appearance of vascular ectasias and the presence or absence of cirrhosis did not determine outcome of patients.
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Affiliation(s)
- M Ito
- Third Department of Internal Medicine, Kagawa Medical University, Kagawa, Japan
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37
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Abstract
Vascular malformations of the gastrointestinal tract may be diagnosed at any age. They may present with bleeding, anaemia, or if they form a mass lesion, with intussusception. Many lesions remain asymptomatic. In a minority of patients there are well-defined genetic conditions present, such as hereditary haemorrhagic telangiectasia. In others, particularly the angiodysplastic lesions that occur in the caecum in elderly patients, the lesions appear to be degenerative. Vascular malformations may affect any section of the gastrointestinal tract, and in some patients there are vascular anomalies elsewhere, particularly in the skin. Diagnosis is usually based on recognition endoscopically, or at angiography. Symptomatic lesions that are discrete and localized respond well to local treatment with laser or heat coagulation or sclerotherapy. Mass lesions, diffuse lesions and severe bleeding may require surgery.
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Affiliation(s)
- F H Gordon
- Royal Free Hospital and Royal Free, University College School of Medicine, Rowland Hill Street, London, NW3 2PF, UK
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38
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Elkayam O, Oumanski M, Yaron M, Caspi D. Watermelon stomach following and preceding systemic sclerosis. Semin Arthritis Rheum 2000; 30:127-31. [PMID: 11071584 DOI: 10.1053/sarh.2000.9623] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To report two patients with watermelon stomach associated with systemic sclerosis (SSc) and review the literature on that subject. METHODS We describe the clinical presentation, course and outcome of our two patients and reviewed the medical literature registered in the MedLine PubMed database from 1966 to 1999 by using the key words watermelon stomach, gastric antral vascular ectasia, systemic sclerosis, scleroderma. RESULTS The two patients presented with microcytic hypochromic anemia. Esophagogastroscopy showed multiple linear vascular malformations in the antrum compatible with watermelon stomach. They responded to Nd-Yag laser therapy with resolution of the lesions and improvement of the anemia. Patient 1 had a history of diffuse SSc while patient 2 developed limited SSc 2 years after the diagnosis of watermelon stomach. A literature review disclosed 16 documented case reports of watermelon stomach associated with SSc, 14 of whom were women. In most cases, watermelon stomach occurred in patients with established SSc but in some it antedated it by several years. In many cases, other autoimmune syndromes such as hypothyroidism, primary biliary cirrhosis, and Sjögren's syndrome were present. The presenting symptom was iron deficiency anemia, which in 11 cases was severe enough to require blood transfusions. Nine patients were successfully treated with several transendoscopic treatments, four required surgical intervention, and in three treatment was not specified. CONCLUSION Although watermelon stomach is a rare syndrome, it is recognized as a cause of persistent bleeding in patients with SSc. Awareness of this condition may increase its recognition and treatment.
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Affiliation(s)
- O Elkayam
- Department of Rheumatology, Tel Aviv Medicine, University of Tel Aviv, Israel
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39
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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: 113] [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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41
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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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42
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Ikeda M, Hayashi N, Imamura E, Kaneko A, Michida T, Yamamoto K, Kurosawa K, Kato M, Masuzawa M. Endoscopic follow-up study of development of gastric antral vascular ectasia associated with liver cirrhosis. J Gastroenterol 1997; 32:587-92. [PMID: 9349982 DOI: 10.1007/bf02934106] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Gastric antral vascular ectasia is an important cause of chronic gastrointestinal blood loss. However, its development and progression have not yet been clarified. We investigated its early lesions and progression by reviewing endoscopic films of five patients with gastric antral vascular ectasia followed for liver cirrhosis. In all patients, early findings were prepyloric red spots. In two patients, anemia due to gastrointestinal bleeding was already observed when vascular lesions were confined to the distal antrum. In the other three patients, anemia was observed 1-2 years after they showed a diagnostic pattern of gastric antral vascular ectasia. The vascular lesions gradually thickened and extended throughout the antrum, with the complete picture shown in 1.5-5 years. The pattern of distribution was classified into three types: diffuse spotty, diffuse confluent, and striped. These types could be predicted before the complete formation. Gastric antral vascular ectasia associated with liver cirrhosis started as prepyloric red spots and extended to the proximal antrum in various ways and varying time courses of less than 5 years; this entity may cause hemorrhage even in the early stage.
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Affiliation(s)
- M Ikeda
- Department of Gastroenterology, Osaka National Hospital, Japan
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43
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Toyota M, Hinoda Y, Nakagawa N, Arimura Y, Tokuchi S, Takaoka A, Kitagawa S, Usuki T, Yabana T, Yachi A, Imai K. Gastric antral vascular ectasia causing severe anemia. J Gastroenterol 1996; 31:710-3. [PMID: 8887039 DOI: 10.1007/bf02347621] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastric antral vascular ectasia (GAVE) that caused continuous gastrointestinal bleeding is reported in a 76-year-old woman who had been treated with repeated blood transfusions because of severe anemia. Endoscopic examination was performed and diffuse speckled telangiectasia of the entire antrum was observed. Laboratory data showed SGOT > SGPT, decreased chE level and the increased levels of serum gastrin and ICG at 15 min. Anti-HCV antibody was positive. Image examination revealed splenomegaly. There was no family history of telangiectasia, and no telangiectasia was found in other organs. The diagnosis was established as GAVE with liver cirrhosis. Surgical resection of the distal stomach resulted in termination of the bleeding, and the cirrhotic changes of the surface of the liver were revealed at that time, providing further evidence of liver cirrhosis. Although the pathogenesis of GAVE is unknown, liver cirrhosis and hypergastrinemia are thought to be associated with the condition. Importantly, this condition is a cause of severe gastrointestinal bleeding in elderly patients.
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Affiliation(s)
- M Toyota
- First Department of Internal Medicine, Sapporo Medical University School of Medicine, Japan
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44
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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: 43] [Impact Index Per Article: 1.5] [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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45
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Ralevic V, Mathie RT, Moore KP, Burnstock G. Vasoconstrictor responsiveness of the rat mesenteric arterial bed in cirrhosis. Br J Pharmacol 1996; 118:435-41. [PMID: 8735649 PMCID: PMC1909631 DOI: 10.1111/j.1476-5381.1996.tb15421.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
1. The effects of cirrhosis on mesenteric vascular reactivity were assessed in constantly perfused mesenteric arterial beds isolated from cirrhotic rats (carbon tetrachloride with phenobarbitone, n = 6), and from phenobarbitone-treated and untreated age-matched controls (n = 4,5). 2. At a constant flow rate of 5 ml min-1 there was no difference in basal perfusion pressure between the groups. Electrical field stimulation (EFS; 4-32 Hz, 90V, 1 ms, 30 s) of perivascular nerves caused frequency-dependent increases in perfusion pressure which were not different between the groups. Dose-dependent vasoconstrictor responses to exogenous noradrenaline (NA), methoxamine (an alpha 1-adrenoceptor agonist), adenosine 5'-triphosphate (ATP) and vasopressin were also similar between the groups. 3. The nitric oxide (NO) synthesis inhibitor NG-nitro-L-arginine methyl ester (L-NAME; 30 microM) augmented constrictor responses to NA, EFS, methoxamine and vasopressin in all groups, and as shown for EFS and NA, this was reversed by L-arginine (300 microM). However, the maximum constrictor responses of cirrhotic preparations in the presence of L-NAME were significantly lower than those of both groups of control animals at the highest frequency of EFS (32 Hz) and highest doses of NA (0.15 and 0.5 mumol) and, compared to phenobarbitone-treated controls, methoxamine (5 mumol). Responses to ATP were significantly augmented by L-NAME only in the cirrhotic group. 4. A step-wise increase in perfusate flow to 10, 15 and 20 ml min-1 produced a broadly similar increase in perfusion pressure within each group. At increased flow rates, cirrhotic preparations were hyporesponsive to NA (15 nmol) compared to the phenobarbitone-treated animals but not the untreated controls. Glibenclamide (5 microM) or L-NAME (30 microM) had no significant effect on the relationship between flow and perfusion pressure or on responses to NA at the different flow rates. 5. We conclude that sympathetic neurotransmission is unchanged in cirrhosis. Endogenous NO is important in modulation of constriction in both normal and cirrhotic states. Changes in NO may occur in cirrhosis, although the role of this in hyporesponsiveness of cirrhotic preparations to NA at higher flow rates and to the greater potentiation of ATP-mediated constriction in the presence of L-NAME, together with the impact of factors such as changes in calcium and potassium channels, is not entirely clear.
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Affiliation(s)
- V Ralevic
- Department of Anatomy and Developmental Biology, University College London
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46
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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: 13] [Impact Index Per Article: 0.4] [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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47
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Watson M, Hally RJ, McCue PA, Varga J, Jiménez SA. Gastric antral vascular ectasia (watermelon stomach) in patients with systemic sclerosis. ARTHRITIS AND RHEUMATISM 1996; 39:341-6. [PMID: 8849390 DOI: 10.1002/art.1780390226] [Citation(s) in RCA: 82] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This report describes 5 patients with systemic sclerosis (SSc) who developed severe, recurrent upper gastrointestinal (GI) bleeding due to gastric antral vascular ectasia (GAVE). The clinical records, the endoscopic findings, and the histologic appearance of biopsy specimens and surgically resected gastric tissue from the patients were reviewed. All 5 patients developed severe and recurrent episodes of upper GI bleeding leading to severe anemia requiring multiple transfusions. The cutaneous involvement was diffuse in 3 patients and limited in 2. All but 1 had cutaneous telangiectasias. The diagnosis of GAVE was established by endoscopy within 3 years of the diagnosis of SSc in all cases. One patient required heater probe cautery, 2 required laser coagulation, and 2 underwent surgical resection of the gastric antrum for control of the GI bleeding. The possibility of GAVE should be considered in SSc patients who have recurrent upper GI bleeding. It is suggested that the antral vascular lesions in these patients may represent a component of the spectrum of vascular alterations of SSc.
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Affiliation(s)
- M Watson
- Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Charneau J, Petit R, Calès P, Dauver A, Boyer J. Antral motility in patients with cirrhosis with or without gastric antral vascular ectasia. Gut 1995; 37:488-92. [PMID: 7489933 PMCID: PMC1382898 DOI: 10.1136/gut.37.4.488] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Gastric motility has not been extensively studied in patients with cirrhosis and gastric antral vascular ectasia (GAVE) may be associated with antropyloric dysfunction. This study therefore looked at antral motility using ultrasound in patients with alcoholic cirrhosis with or without GAVE. Twenty six patients were included: 10 patients with cirrhosis without GAVE, eight patients with cirrhosis and GAVE, and eight controls without liver disease. Measurement of antral area and antral contractions (amplitude and frequency) was performed for three hours after ingestion of a standardised solid-liquid meal. Antral area half time (mean (SD)) was not significantly increased in patients with cirrhosis without GAVE (84 (42) min), but increased by 120% (123 (43) min; p < 0.01) in patients with GAVE compared with controls (56 (26) min). GAVE patients exhibited the same frequency and amplitude of antral contractions at each time point as controls and had the same tendency to increase these values over time although this was attenuated in the late postprandial phase. In contrast, cirrhotic patients without GAVE exhibited a significantly higher frequency and amplitude of antral contractions during the initial postprandial phase but showed no change in either frequency or amplitude over time. In conclusion, in cirrhosis there is an abnormal antral motor response to a meal, which has a different pattern over time in patients with or without GAVE.
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Affiliation(s)
- J Charneau
- Department of Hepato-Gastroenterology, University Hospital, Angers, France
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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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Abstract
Stomach function and secretions are altered significantly in patients with cirrhosis, both with or without portal hypertension. This review covers the abnormalities of gastric acid and pepsin secretion, and gastrin release. Histological and endoscopic changes, and the impaired cytoprotection associated with cirrhosis, are discussed in the context of abnormal gastric secretion. In addition, the symptomatology and association of H. pylori, and treatment of duodenal ulceration in cirrhosis are discussed. It is clear from this review that additional studies are needed to further understand gastric function in cirrhotic patients.
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Affiliation(s)
- A G Fraser
- University Department of Medicine, Royal Free Hospital School of Medicine, London, UK
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