Gastric antral vascular ectasia (GAVE) is an unusual cause of upper gastrointestinal (GI) bleeding in an elderly patient.

A 73-year-old female with erosive gastritis, hypertension, and unstable angina arrived at the emergency department with shortness of breath, easy fatigability, and melaena. Physical examination indicated pallor but no signs of distress, with an unremarkable systemic examination. Routine blood testing indicated anemia. The patient underwent upper gastrointestinal endoscopy, which revealed linear red ectatic vessels radiating from the antrum towards the body. A diagnosis of GAVE was made. Blood transfusions and argon plasma coagulation were undertaken.

This condition is an uncommon cause of upper GI bleeding with the antrum being the most prevalent site. The pathophysiology of GAVE is yet unknown, however, many hypotheses have been postulated. GAVE is frequently misdiagnosed as gastritis. GAVE treatment comprises initial resuscitation and symptomatic treatment with intravenous fluids and blood products. Endoscopy has increasingly been the first-line therapeutic option for GAVE in recent years, including argon plasma coagulation.

The diagnosis of gastric antral vascular ectasia is frequently overlooked during upper GI endoscopy, despite the fact that it should always be explored, especially in cases of unexplained GI bleeding in the elderly.

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An unusual cause of upper gastrointestinal bleeding in an elderly patient.

• BRTO
• Cirrhosis
• Early TIPS
• Endoscopy
• Esophageal varices
• Gastric varices
• Gastrointestinal bleeding
• Portal hypertension
• Primary prophylaxis
• Secondary prophylaxis

• Gastric antral vascular ectasia
• Gastrointestinal bleeding
• Pathogenesis
• Pharmacotherapy
• Refractory anemia

• Chronic Disease
• Endoscopy
• Gastric Antral Vascular Ectasia/drug therapy
• Gastrointestinal Hemorrhage/drug therapy
• Humans
• Recurrence

• argon plasma coagulation
• endoscopic band ligation
• gastric antral vascular ectasia
• radiofrequency ablation

Gastric antral vascular ectasia (GAVE) syndrome is a rare but significant cause of acute or chronic gastrointestinal (GI) bleeding, particularly in the elderly. The primary objective of this study was to determine the biodemographic characteristics, adverse outcomes, and the impact of GAVE hospitalizations on the US healthcare system.

This retrospective database cross-sectional study used the National Inpatient Sample (NIS) from 2001 to 2011 to identify all adult hospitalizations with a primary discharge diagnosis of GAVE, with and without hemorrhage, using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Individuals less than 17 years of age were excluded from the study. The outcomes included biodemographic characteristics, comorbidity measures, and inpatient mortality and the burden of the disease on the US healthcare system in terms of healthcare cost and utilization.

We noted an increase in the total hospitalizations for GAVE from 25,423 in 2001 to 44,787 in 2011. Furthermore, GAVE hospitalizations with hemorrhage rose from 19,168 in 2001 to 27,679 in 2011 while GAVE hospitalization without hemorrhage increased from 6,255 in 2001 to 17,108 in 2011. We also noted a female predominance, the proportional trend of which did not show significant difference from 2001 to 2011. For GAVE hospitalizations, the inpatient mortality decreased from 2.20% in 2001 to 1.73% in 2011. However, the cost of hospitalization increased from $11,590 in 2001 to $12,930 in 2011. After adjusting for possible confounders, we observed that the presence of hemorrhage in GAVE hospitalizations was associated with an increased risk of mortality (odds ratio (OR): 1.27; 95% confidence interval (CI): 1.1 - 1.46; P = 0.001).

For the study period, the total number of GAVE hospitalizations increased with an increase noted in the proportion of GAVE hospitalizations without bleeding, reflecting an improvement in diagnostic and therapeutic techniques. Although inpatient mortality for GAVE slightly decreased, we noted a significant increase in the cost of care likely secondary to increased use of advanced and expensive interventions.

• Comorbidities
• Cost of care
• Gastric antral vascular ectasia
• Hemorrhage
• Mortality
• Nationwide inpatient sample
• Outcome
• Predictors of mortality

• GAVE
• cirrhosis
• thalidomide

Refractory gastrointestinal bleeding (GIB) secondary to gastrointestinal vascular malformations (GIVM) such as gastrointestinal angiodysplasia (GIAD) and gastric antral vascular ectasia (GAVE) remains challenging to treat when endoscopic therapy fails. Recently thalidomide has been suggested as a treatment option for refractory GIB.

To determine the outcome of patients treated with thalidomide for refractory GIB due to GIVM.

IRB approved, single center, retrospective review of electronic medical records from January 2012 to November 2018. Patients age > 18 years old, who had > 3 episodes of GIB refractory to medical or endoscopic therapy, and who had been treated with thalidomide for at least 3 mo were included. The primary endpoint was recurrence of GIB 6 mo after initiation of thalidomide.

Fifteen patients were included in the study, all with significant cardiac, hepatic, or renal comorbidities. The cause of GIB was GIAD in 10 patients and GAVE in 5 patients. Two patients were lost to follow up. Of the 13 patients followed, 38.5% (n = 5) had no recurrent GIB or transfusion requirement after treatment with thalidomide. Furthermore, 84.6% (n = 11) of patients had a reduction in transfusion requirements and hospitalizations for GIB. Thalidomide was discontinued in 2 patients due to cost (n = 1) and medication interaction (n = 1). Reported adverse reactions included fatigue (n = 3), neuropathy (n = 2), dizziness (n = 1), and constipation (n = 1). Six patients died during follow up due to unknown cause (n = 4) and sepsis (n = 2).

Thalidomide appears to be an effective treatment for refractory GIB due to GIAD or GAVE in a Western population with significant comorbidities.

• Vascular malformation
• Thalidomide
• Refractory gastrointestinal bleeding
• Gastric antral vascular ectasia
• Angiodysplasia

• CRP
• Cancer
• EUS
• GAVE

• endoscopy
• gastric antral vascular ectasia
• gastrointestinal bleeding

• antrectomy
• endoscopic hemostasis
• gastric antral vascular ectasia
• gastrointestinal bleeding

GAVE is an uncommon cause of upper nonvariceal bleeding and often manifests itself as occult bleeding with chronic anemia. To date, the standard of care for GAVE is endoscopic treatment with thermoablative techniques. Despite good technical results, approximately two thirds of patients remain dependent on transfusions after the therapy. One of the emerging and more promising endoscopic treatments for GAVE is radiofrequency ablation (RFA). The aim of this study is to perform a systematic review of literature in order to assess current evidence supporting the effectiveness of this technique for treatment of refractory GAVE.

Through electronic search, we identified 14 records, and after removal of duplicates and irrelevant studies, we selected 10 studies on radiofrequency ablation of GAVE: 4 prospective open-label single-center studies, 1 retrospective multicentric study, and 5 case reports.

Among all 72 treated patients reported in literature, 74.3% achieved a clinical response, while nonfatal AEs have been reported in 4.2% of cases.

Despite some qualitative limitations, all literature data support effectiveness of RFA for treatment of refractory GAVE. In the future, large prospective controlled trials with adequate follow-up are needed to better assess the effectiveness and safety of this procedure.

• Barrx
• endoscopic treatment
• gastric antral vascular ectasia
• radiofrequency ablation

• Endoscopy
• Gastric antral vascular ectasia
• Gastrointestinal bleeding
• Stomach

• Cost-Benefit Analysis
• Gastrointestinal Agents/therapeutic use
• Gastrointestinal Hemorrhage/drug therapy
• Gastrointestinal Hemorrhage/etiology
• Humans
• Octreotide/therapeutic use
• Off-Label Use
• Vascular Malformations/complications

AIM: To systematically review the data on distinctive aspects of peptic ulcer disease (PUD), Dieulafoy’s lesion (DL), and Mallory-Weiss syndrome (MWS) in patients with advanced alcoholic liver disease (aALD), including alcoholic hepatitis or alcoholic cirrhosis.

METHODS: Computerized literature search performed via PubMed using the following medical subject heading terms and keywords: “alcoholic liver disease”, “alcoholic hepatitis”,“ alcoholic cirrhosis”, “cirrhosis”, “liver disease”, “upper gastrointestinal bleeding”, “non-variceal upper gastrointestinal bleeding”, “PUD”, ‘‘DL’’, ‘‘Mallory-Weiss tear”, and “MWS’’.

RESULTS: While the majority of acute gastrointestinal (GI) bleeding with aALD is related to portal hypertension, about 30%-40% of acute GI bleeding in patients with aALD is unrelated to portal hypertension. Such bleeding constitutes an important complication of aALD because of its frequency, severity, and associated mortality. Patients with cirrhosis have a markedly increased risk of PUD, which further increases with the progression of cirrhosis. Patients with cirrhosis or aALD and peptic ulcer bleeding (PUB) have worse clinical outcomes than other patients with PUB, including uncontrolled bleeding, rebleeding, and mortality. Alcohol consumption, nonsteroidal anti-inflammatory drug use, and portal hypertension may have a pathogenic role in the development of PUD in patients with aALD. Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients. The frequency of bleeding from DL appears to be increased in patients with aALD. DL may be associated with an especially high mortality in these patients. MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism, and is associated with aALD. Patients with aALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics. Pre-endoscopic management of acute GI bleeding in patients with aALD unrelated to portal hypertension is similar to the management of aALD patients with GI bleeding from portal hypertension, because clinical distinction before endoscopy is difficult. Most patients require intensive care unit admission and attention to avoid over-transfusion, to correct electrolyte abnormalities and coagulopathies, and to administer antibiotic prophylaxis. Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal. Prompt endoscopy, after initial resuscitation, is essential to diagnose and appropriately treat these patients. Generally, the same endoscopic hemostatic techniques are used in patients bleeding from PUD, DL, or MWS in patients with aALD as in the general population.

CONCLUSION: Nonvariceal upper GI bleeding in patients with aALD has clinically important differences from that in the general population without aALD, including: more frequent and more severe bleeding from PUD, DL, or MWS.

• Alcoholic liver disease
• Alcoholic hepatitis
• Cirrhosis
• Portal hypertension
• Peptic ulcer disease
• Mallory-Weiss syndrome
• Dieulafoy lesion
• Endoscopic therapy

• Arteries/pathology
• Endoscopy, Gastrointestinal
• Female
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/pathology
• Gastrointestinal Hemorrhage/therapy
• Humans
• Hypertension, Portal/complications
• Liver Cirrhosis/complications
• Liver Diseases, Alcoholic/complications
• Male
• Mallory-Weiss Syndrome/etiology
• Peptic Ulcer/etiology
• Risk Factors

• Argon plasma coagulation
• Liver disease
• Portal hypertension

• GI bleeding
• Liver cirrhosis
• Portal hypertension
• Transjugular intrahepatic portosystemic shunt (TIPS)

• cirrhosis
• management
• upper gastrointestinal bleeding

• Argon plasma coagulation
• End-stage kidney disease
• Gastric antral vascular ectasia
• Haemodialysis

• Angiodysplasia
• Comparison Analysis
• Gastric Antral Vascular Ectasia
• Systematic Review

• Gastric antral vascular ectasia
• Liver cirrhosis
• Portal hypertensive gastropathy

• BRTO
• Endoscopic band ligation
• GAVE
• Gastric varices
• Portal hypertensive gastropathy
• TIPS

• Adrenergic beta-Antagonists/therapeutic use
• Endoscopy, Gastrointestinal
• Esophageal and Gastric Varices/diagnosis
• Esophageal and Gastric Varices/etiology
• Esophageal and Gastric Varices/therapy
• Gastrointestinal Hemorrhage/diagnosis
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/therapy
• Humans
• Hypertension, Portal/complications
• Hypertension, Portal/diagnosis
• Liver Cirrhosis/complications
• Liver Cirrhosis/diagnosis

• Endoscopy
• GAVE
• Gastric antral vascular ectasia
• Gastrointestinal bleeding

• Aged
• Argon Plasma Coagulation
• Blood Transfusion
• Disease Management
• Endoscopy, Gastrointestinal
• Female
• Gastric Antral Vascular Ectasia/diagnosis
• Gastric Antral Vascular Ectasia/pathology
• Gastric Antral Vascular Ectasia/therapy
• Humans
• Male
• Middle Aged
• Recurrence
• Treatment Outcome

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.

• Gastric antral vascular ectasia
• Bleeding
• Watermelon stomach
• Argon plasma coagulation

• Taenia solium
• cysticercosis
• inflammation.
• progesterone
• sex hormones

• Animals
• Cricetinae
• Female
• Humans
• Immunity, Mucosal/drug effects
• Interleukin-4/metabolism
• Interleukin-6/metabolism
• Intestines/parasitology
• Mesocricetus
• Progesterone/therapeutic use
• Rats
• Swine
• Taenia solium/drug effects
• Taenia solium/immunology
• Taenia solium/pathogenicity
• Taeniasis/drug therapy
• Taeniasis/immunology
• Taeniasis/parasitology
• Tumor Necrosis Factor-alpha/metabolism

• Argon Plasma Coagulation
• Diagnosis, Differential
• Gastric Antral Vascular Ectasia/diagnosis
• Gastric Antral Vascular Ectasia/etiology
• Gastric Antral Vascular Ectasia/physiopathology
• Gastric Antral Vascular Ectasia/surgery
• Gastrointestinal Hemorrhage/drug therapy
• Gastrointestinal Hemorrhage/etiology
• Humans
• Hypertension, Portal/complications
• Hypertension, Portal/drug therapy
• Hypertension, Portal/etiology
• Liver Cirrhosis/complications
• Stomach Diseases/diagnosis
• Stomach Diseases/drug therapy
• Stomach Diseases/etiology
• Stomach Diseases/physiopathology

• P30 DK34989 NIDDK NIH HHS

• Argon plasma coagulation
• Endoscopic band ligation
• Gastric antral vascular ectasia
• Liver cirrhosis

• portal hypertensive gastropathy
• gastric antral vascular ectasia
• portal hypertension
• cirrhosis
• management

• Adult
• Aged
• Argon/therapeutic use
• Autoantibodies/analysis
• Electrocoagulation/methods
• Female
• Follow-Up Studies
• Gastric Antral Vascular Ectasia/immunology
• Gastric Antral Vascular Ectasia/surgery
• Gastrointestinal Hemorrhage/immunology
• Gastrointestinal Hemorrhage/surgery
• Hemostasis, Endoscopic/methods
• Humans
• Male
• Middle Aged
• Sex Factors
• Treatment Outcome

• Adenoma/surgery
• Aged
• Argon
• Diabetes Complications
• Female
• Gastroscopy
• Humans
• Laser Coagulation/methods
• Male
• Middle Aged
• Stomach Neoplasms/surgery