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Caputo J, Reagans R, Chen W, Choe H. Gastric antral vascular ectasia as a manifestation of liver graft versus host disease responsive to ruxolitinib. BMJ Case Rep 2025; 18:e259880. [PMID: 40287161 DOI: 10.1136/bcr-2024-259880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2025] Open
Abstract
Gastric antral vascular ectasia (GAVE) or 'watermelon stomach' is a rare angio-dysplastic disorder causing gastric bleeding. The aetiology of GAVE is unknown, but it is associated with several conditions including autoimmune disease, chronic renal failure and liver disorders. It can also develop as a complication of haematopoietic stem cell transplantation (HSCT)-GAVE, most associated with conditioning regimens including busulfan. HSCT-GAVE has also been linked with thrombotic microangiopathy and graft versus host disease (GVHD), but the relationship is poorly understood. This report presents a patient status post-allogeneic HSCT who developed severe refractory GAVE, ultimately found to be a manifestation of liver GVHD responsive to treatment with ruxolitinib.
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Affiliation(s)
- Jean Caputo
- Hematology, The Ohio State University James Cancer Hospital, Columbus, Ohio, USA
| | - Ryan Reagans
- Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Wei Chen
- Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hannah Choe
- Hematology, The Ohio State University James Cancer Hospital, Columbus, Ohio, USA
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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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Girão de Caires F, Nunes M, Damiao F, Dionísio I, Gomes da Costa A. Anemia Secondary to Gastric Antral Vascular Ectasia Successfully Treated With Antral Gastrectomy. Cureus 2024; 16:e69663. [PMID: 39429396 PMCID: PMC11488673 DOI: 10.7759/cureus.69663] [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: 09/18/2024] [Indexed: 10/22/2024] Open
Abstract
Gastric antral vascular ectasia (GAVE) is a rare but significant cause of chronic gastrointestinal bleeding and anemia, particularly in elderly patients. We report the case of a 75-year-old female who presented with severe anemia secondary to GAVE. Despite multiple endoscopic interventions with argon plasma coagulation (APC) treatments and endoscopic band ligation (EBL), the patient's condition persisted, necessitating an antral gastrectomy with intraoperative endoscopy to delineate the proximal resection margin. Postoperative outcomes were favorable, with no recurrence of anemia or gastrointestinal bleeding observed during follow-up.
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Affiliation(s)
| | - Mafalda Nunes
- General Surgery, Unidade Local de Saúde do Oeste, Caldas da Rainha, PRT
| | - Filipe Damiao
- Gastroenterology, Unidade Local de Saúde do Oeste, Caldas da Rainha, PRT
| | - Isabel Dionísio
- General Surgery, Unidade Local de Saúde do Oeste, Caldas da Rainha, PRT
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Kravchenko T, Chaudhry A, Khan Z. Upper gastrointestinal bleeding from gastric antral vascular ectasia following cocaine use: case presentation and review of literature. Folia Med (Plovdiv) 2023; 65:681-685. [PMID: 37655392 DOI: 10.3897/folmed.65.e89756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/08/2022] [Indexed: 09/02/2023] Open
Abstract
Gastric antral vascular ectasia (GAVE), also known as "Watermelon stomach", is a rare cause of upper gastrointestinal bleeding (UGIB). It is characterized by an endoscopic appearance of flat red blood vessels traveling from the pylorus to the antrum. Patients often present with chronic blood loss resulting in iron deficiency anemia, or, less commonly, with acute gastropathy resulting in massive hemorrhage. The etiology of GAVE is unknown but the disorder has been more commonly observed in patients with cirrhosis, especially with portal hypertension, as well as in those with systemic sclerosis and other connective tissue disease. There is no definitive cure for GAVE, but the condition can be managed with a variety of endoscopic techniques, including heater probes, bipolar probes, plasma coagulators, laser therapy, and radiofrequency ablation. In rare cases, patients also require blood transfusions. Here we present an interesting case of upper GI bleeding resulting in symptomatic anemia in a 69-year-old female patient with GAVE following cocaine use. The patient was initially admitted for fatigue and shortness of breath and required multiple units of pRBCs. She was also found to have a urine drug screen positive for cocaine. Following stabilization, she underwent endoscopy which revealed the characteristic "watermelon stomach" appearance consistent with GAVE syndrome. The patient was discharged on an oral proton-pump inhibitor with instructions to follow-up outpatient with Gastroenterology. This case is presented as an example of a risk factor for acute exacerbation of a rare cause of UGIB. This patient presentation also represents an example of the importance of strict follow-up for those with risk factors for exacerbation of chronic GI conditions.
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Affiliation(s)
- Timothy Kravchenko
- Rutgers Robert Wood Johnson Medical School, New Brunswick, United States of America
| | - Aasim Chaudhry
- Centrastate Medical Center, Freehold, United States of America
| | - Zeeshan Khan
- Centrastate Medical Center, Freehold, United States of America
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Marginean CM, Pirscoveanu D, Popescu M, Docea AO, Radu A, Popescu AIS, Vasile CM, Mitrut R, Marginean IC, Iacob GA, Firu DM, Mitrut P. Diagnostic Approach and Pathophysiological Mechanisms of Anemia in Chronic Liver Disease—An Overview. GASTROENTEROLOGY INSIGHTS 2023; 14:327-341. [DOI: 10.3390/gastroent14030024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2025] Open
Abstract
Hematological abnormalities are frequently linked to chronic liver disease of any etiology. About 75% of patients with advanced chronic liver disease experience anemia. The causes of anemia are complex and multifactorial, particularly in cirrhotic patients. Acute and long-term blood loss from the upper gastrointestinal tract, malnutrition, an enlarged spleen brought on by portal hypertension, hemolysis, and coagulation issues are the main causes of anemia. Alcohol, a common cause of chronic liver disease, determines anemia through direct toxicity on the bone marrow, with the suppression of hematopoiesis, through vitamin B6, B12, and folate deficiency due to low intake and malabsorption. In patients with chronic hepatitis C virus infection, antiviral drugs such as pegylated interferon and ribavirin can also cause significant anemia. The use of interferon has been linked to bone marrow toxicity, and hemolytic anemia brought on by ribavirin is a well-known dose-dependent side effect. Within six months of the infection with hepatitis B, hepatitis C, and Epstein–Barr viruses, aplastic anemia associated with hepatitis is seen. This anemia is characterized by pancytopenia brought on by hypocellular bone marrow. Esophageal varices, portal hypertensive gastropathy, and gastric antral vascular ectasia can all cause acute and chronic blood loss. These conditions can progress to iron deficiency anemia, microcytic anemia, and hypochromic anemia. Another common hematologic abnormality in liver cirrhosis is macrocytosis, with multifactorial causes. Vitamin B12 and folate deficiency are frequent in liver cirrhosis, especially of alcoholic etiology, due to increased intestinal permeability, dysbiosis, and malnutrition. Many chronic liver diseases, like viral and autoimmune hepatitis, have a chronic inflammatory substrate. Proinflammatory cytokines, including tumor necrosis factor and interleukin 1, 6, and 10, are the main factors that diminish iron availability in progenitor erythrocytes and subsequent erythropoiesis, leading to the development of chronic inflammatory, normochromic, normocytic anemia.
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Affiliation(s)
- Cristina Maria Marginean
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Denisa Pirscoveanu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mihaela Popescu
- Department of Endocrinology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Anca Oana Docea
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Antonia Radu
- Department of Pharmaceutical Botany, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | | | - Corina Maria Vasile
- Department of Pediatric and Adult Congenital Cardiology, Bordeaux University Hospital, 33600 Pessac, France
| | - Radu Mitrut
- Department of Cardiology, University and Emergency Hospital, 050098 Bucharest, Romania
| | | | - George Alexandru Iacob
- Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Dan Mihai Firu
- Department of Medical Semiology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Paul Mitrut
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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Zhang C, Wang Y, Zhang D, Li S. Colonoscopic and Clinical Features of Colonic Angiodysplasia: A Study in 54 Patients. Surg Laparosc Endosc Percutan Tech 2023; 33:115-120. [PMID: 36944226 PMCID: PMC10065816 DOI: 10.1097/sle.0000000000001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 01/31/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVES Colonic angiodysplasia is a rare disease, it is nevertheless a common cause of lower gastrointestinal (GI) bleeding in older adults. The study summarized the colonoscopic and clinical features of colonic angiodysplasia to raise awareness among endoscopists regarding this disease. MATERIALS AND METHODS We performed a retrospective study of enrolled patients diagnosed with colonic angiodysplasia between September 2013 and April 2022. Clinical and colonoscopic features of the patients with active bleeding were analyzed and compared with those of patients without bleeding. The comparisons were also conducted between the patients with active lower GI bleeding caused by colonic angiodysplasia and those by other diseases. RESULTS In total, 54 eligible patients were included in this study; 55.55% of the participants were aged over 60 years. Ten patients (3 men and 7 women) with colonic angiodysplasia suffered from active lower GI bleeding, which was mainly located in the left and total colon. The patients with type 2 diabetes mellitus, radiotherapy history, antiplatelet drug use, and multiple lesions were more likely to endure lower GI bleeding. The duration between bleeding and admission was longer in the colonic angiodysplasia group than in the other diseases group ( P = 0.043). In the colonic angiodysplasia group, bleeding relapsed in 3 patients, and the recurrence rate was higher than in the other diseases group ( P < 0.001). CONCLUSION Endoscopists should perform colonoscopy scrupulously and consider colonic angiodysplasia as a differential diagnosis in patients with lower GI bleeding, especially for older women and adults with chronic diseases, such as type 2 diabetes mellitus.
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Gairing SJ, Schleicher EM, Müller L, Labenz C, Darstein F, Grimm D, Sivanathan V, Weinmann A, Wörns MA, Kloeckner R, Pitton MB, Thieringer F, Rahman KF, Galle PR, Schattenberg JM, Foerster F. Bevacizumab in combination with octreotide rescues a patient with liver cirrhosis, GAVE syndrome and refractory hemorrhage - a case report. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:275-279. [PMID: 36379462 DOI: 10.1055/a-1959-2660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Gastric antral vascular ectasia (GAVE) syndrome is a rare but often challenging etiology of upper gastrointestinal bleeding (UGIB).We report on a 60-year-old patient with liver cirrhosis, GAVE syndrome and recurrent and refractory GAVE-related UGIB. During a 5-month hospital stay, the patient required a total of 82 packed red blood cells (pRBCs) and 23 gastroscopies. All endoscopic approaches, including multiple argon plasma coagulation and band ligation sessions, remained unsuccessful. Antrectomy was waived because of the high perioperative mortality risk in Child-Pugh B liver cirrhosis. TIPS insertion also failed to control the bleeding. Only continuous intravenous octreotide infusion slowed the bleeding, but this forced the patient to be hospitalized. After 144 inpatient days, administration of subcutaneous octreotide allowed the patient to be discharged. However, the patient continued to require two pRBCs every 2-3 weeks. Based on recently published data, we treated the patient with bevacizumab (anti-VEGF antibody) off-label at a dose of 7.5 mg/kg body weight every three weeks in nine single doses over six months. Since the first administration, the patient has remained transfusion-free, has not required hospitalization, and leads an active life, working full-time. He remains on octreotide, which has been reduced but not yet discontinued. Additionally, no adverse events were observed.Thus, in patients with liver cirrhosis and refractory GAVE-related hemorrhage, bevacizumab combined with subcutaneous octreotide should be considered as an effective and durable pharmacological treatment option.
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Affiliation(s)
- Simon Johannes Gairing
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eva Maria Schleicher
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Lukas Müller
- Department of Diagnostic and Interventional Radiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Felix Darstein
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Daniel Grimm
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Visvakanth Sivanathan
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Arndt Weinmann
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Marcus-Alexander Wörns
- Department of Gastroenterology, Hematology, Oncology and Endocrinology, Hospital Dortmund, Dortmund, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michael B Pitton
- Department of Diagnostic and Interventional Radiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Florian Thieringer
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Khan Fareed Rahman
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Peter Robert Galle
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jörn M Schattenberg
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Friedrich Foerster
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
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Fujimori S. Tranexamic acid may be a useful pharmacotherapy for endoscopically resistant small bowel angiodysplasia. World J Gastroenterol 2023; 29:1131-1138. [PMID: 36926669 PMCID: PMC10011953 DOI: 10.3748/wjg.v29.i7.1131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/23/2022] [Accepted: 02/01/2023] [Indexed: 02/21/2023] Open
Abstract
Small bowel angiodysplasia (SBAD) is reported to account for nearly 50% of cases of small bowel bleeding. When SBAD occurs frequently, it is difficult to treat all the angiodysplasias endoscopically, and gastrointestinal bleeding often recurs. Hormone therapy, somatostatin analogs, thalidomide and vascular endothelial growth factor (VEGF)-neutralizing antibodies have been reported to reduce gastrointestinal angiodysplasia (GIAD) bleeding. However, there is no strong evidence to recommend them. Also, there are no guidelines for their use. Hereditary hemorrhagic telangiectasia (HHT) is a hereditary disease caused by abnormalities in VEGF, resulting in multiple GIADs. A treatment guideline has been created for GIAD in HHT, and the use of tranexamic acid, an antifibrinolytic agent, is the first recommendation pharmacotherapy for GIAD with gastrointestinal bleeding that is difficult to treat endoscopically. It has been reported that fibrinolysis is accelerated in GIAD patients who are not HHT, similar to HHT patients. The use of tranexamic acid for gastric antral vascular ectasia in GIAD has been reported to be useful. However, there are very few reports of its use for SBAD. There are concerns with tranexamic acid use regarding the development of thrombosis/embolism, but there are few reports of such side effects. Future clinical trials including tranexamic acid for SBAD are desired.
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Affiliation(s)
- Shunji Fujimori
- Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba 270-1694, Japan
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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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Aryan M, Jariwala R, Alkurdi B, Peter S, Shoreibah M. Prevalence of metabolic syndrome in cirrhotics with gastric antral vascular ectasia. Diabetes Metab Syndr 2022; 16:102377. [PMID: 34974327 DOI: 10.1016/j.dsx.2021.102377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND AIMS Gastric antral vascular ectasia (GAVE) is characterized by angliodysplastic lesions that can cause upper gastrointestinal bleeding (UGIB). The mechanism behind GAVE and its association with other diseases remains unknown. We investigated the association of metabolic syndrome in cirrhotic GAVE patients when compared to esophageal variceal hemorrhage (EVH) patients. METHODS We performed a retrospective review of 941 consecutive esophagogastroduodenoscopies (EGDs) for UGIB at a medical center between 2017 and 2019. The GAVE group consisted of EGD or biopsy diagnosed cirrhotic GAVE patients, and the EVH group consisted of EVH patients with active bleeding or stigmata of recent hemorrhage on EGD. Baseline variables including co-morbidities and cirrhotic etiology were recorded. Continuous variables were compared using Wilcoxon test and categorical variables were compared using Chi-square or Fisher's exact test. Multiple logistic regression analysis evaluated the association between GAVE and covariates. RESULTS The final cohort had 96 GAVE and 104 EVH patients. Mean BMI was significantly higher in the GAVE cohort (32.6 vs 27.9, p < 0.0001) in addition to diabetes, hypertension, and hyperlipidemia (53.1% vs 37.5%; 76% vs 47.1%; 38.5% vs 14.4%; respectively, all p < 0.05). Non-alcoholic steatohepatitis (NASH) cirrhosis was more prevalent in GAVE than EVH patients (50% vs 24%, p = 0.0001). Multiple logistics regression revealed female sex, increased BMI, hypertension, and hyperlipidemia all having significantly higher risk of GAVE (all p < 0.05). CONCLUSION Our data indicates that when compared to cirrhotics patients with EVH, cirrhotics with GAVE have increased risk of metabolic syndrome. This may play a role in the underlying pathophysiology of GAVE.
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Affiliation(s)
- Mahmoud Aryan
- Tinsley Harrison Internal Medicine Residency Program, Department of Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, BDB 327, Birmingham, AL, 35294, United States.
| | - Ravi Jariwala
- Tinsley Harrison Internal Medicine Residency Program, Department of Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, BDB 327, Birmingham, AL, 35294, United States; Department of Gastroenterology and Hepatology, Ochsner Medical Center, 1514 Jefferson Hwy. New Orleans, LA, 70121, United States
| | - Basem Alkurdi
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 391, Birmingham, AL, 35294, United States
| | - Shajan Peter
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 391, Birmingham, AL, 35294, United States
| | - Mohamed Shoreibah
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 391, Birmingham, AL, 35294, United States
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Rajabnia M, Hatami B, Ketabi Moghadam P, Mohammadi M, Rafizadeh M, Mangeli F, Fathi M, Jahanian A. Comparison of portal hypertensive gastropathy and gastric antral vascular ectasia: an update. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2022; 15:204-218. [PMID: 36311963 PMCID: PMC9589138 DOI: 10.22037/ghfbb.v15i3.2561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/01/2022] [Indexed: 11/18/2022]
Abstract
Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are two distinct entities that are frequently mistaken with each other, because they present with similar manifestations. This issue may cause catastrophic outcomes, as each one of them has a unique pathophysiology, thereby making their management approaches completely different. There are clinical clues that help physicians distinguish these two. Direct vision via upper endoscopy is often mandatory to establish the diagnosis, and sometimes biopsy is required. In this review, we sought to discuss different aspects of both conditions and highlight clinical evidence that may help in identifying and managing the disease appropriately.
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Affiliation(s)
- Mohsen Rajabnia
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Behzad Hatami
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pardis Ketabi Moghadam
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahsa Mohammadi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mitra Rafizadeh
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Forogh Mangeli
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mobin Fathi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Jahanian
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Jariwala R, Shoreibah M. An Unexpected Association: Might GAVE Pave the Way to How the Metabolic Syndrome Behaves. Clin Liver Dis (Hoboken) 2021; 18:297-300. [PMID: 34976375 PMCID: PMC8688897 DOI: 10.1002/cld.1156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/10/2021] [Accepted: 07/21/2021] [Indexed: 02/04/2023] Open
Abstract
Content available: Audio Recording.
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Affiliation(s)
- Ravi Jariwala
- Internal Medicine Residency Training ProgramUniversity of Alabama at BirminghamBirminghamAL
| | - Mohamed Shoreibah
- Division of Gastroenterology & HepatologyUniversity of Alabama at BirminghamBirminghamAL
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Endoscopic radiofrequency ablation for the treatment of severe gastric antral vascular ectasia in patients with cirrhosis. Eur J Gastroenterol Hepatol 2021; 33:1414-1419. [PMID: 32925507 DOI: 10.1097/meg.0000000000001889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Gastric antral vascular ectasia is a significant cause of gastrointestinal bleeding in patients with cirrhosis. AIM To assess safety/efficacy and cost/advantages of radiofrequency ablation for the treatment of gastric antral vascular ectasia in patients with cirrhosis. MATERIALS AND METHODS Patients with cirrhosis and severe gastric antral vascular ectasia who underwent radiofrequency ablation were enrolled. Clinical data, gastric antral vascular ectasia grade, and gastric antral vascular ectasia-related hospitalizations were collected. Primary outcome was defined as the absence of transfusion over the 6 months after radiofrequency. An economic analysis was performed in the same period. RESULTS Forty patients (50% Child B) were enrolled (80% refractory to argon plasma coagulation). Gastric antral vascular ectasia eradication was obtained in all patients and 65% of these patients achieved primary outcome. After radiofrequency, mean number of red blood cells transfusions dropped (from 25 to 0.9, P < 0.0001), with a parallel increase in hemoglobin (from 8 to 10.5 g/dL, P < 0.0001). No major complication occurred and liver function remained stable in all patients. The cost-analysis demonstrated a profound reduction of health care cost (from € 536.084 to € 189.044 in the 6 months before vs. after radiofrequency, respectively). These results were confirmed in the subgroup analysis in patients refractory to argon plasma coagulation. CONCLUSIONS Radiofrequency ablation is safe and effective for the treatment of gastric antral vascular ectasia in patients with cirrhosis, including those refractory to argon plasma coagulation. Although the cost of single radiofrequency ablation is relatively high, the cost-analysis demonstrated considerable saving.
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Singh SP, Wadhawan M, Acharya SK, Bopanna S, Madan K, Sahoo MK, Bhat N, Misra SP, Duseja A, Mukund A, Anand AC, Goel A, Satyaprakash BS, Varghese J, Panigrahi MK, Tandan M, Mohapatra MK, Puri P, Rathi PM, Wadhwa RP, Taneja S, Thomas V, Bhatia V. Management of portal hypertensive upper gastrointestinal bleeding: Report of the Coorg Consensus workshop of the Indian Society of Gastroenterology Task Force on Upper Gastrointestinal Bleeding. Indian J Gastroenterol 2021; 40:519-540. [PMID: 34890020 DOI: 10.1007/s12664-021-01169-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/09/2021] [Indexed: 02/04/2023]
Abstract
Portal hypertensive bleeding is a major complication of portal hypertension (PHT) with high morbidity and mortality. A lot of advances have been made in our understanding of screening, risk stratification, and management strategies for portal hypertensive bleeding including acute variceal bleeding leading to improved overall outcomes in patients with PHT. A number of guidelines on variceal bleeding have been published by various societies in the past few years. The Indian Society of Gastroenterology (ISG) Task Force on Upper Gastrointestinal Bleeding (UGIB) felt that it was necessary to bring out a standard practice guidance document for the use of Indian health care providers especially physicians, gastroenterologists, and hepatologists. For this purpose, an expert group meeting was convened by the ISG Task Force to deliberate on this matter and write a consensus guidance document for Indian practice. The delegates including gastroenterologists, hepatologists, radiologists, and surgeons from different parts of the country participated in the consensus development meeting at Coorg in 2018. A core group was constituted which reviewed all published literature on portal hypertensive UGIB with special reference to the Indian scenario and prepared unambiguous statements on different aspects for voting and consensus in the whole group. This consensus was produced through a modified Delphi process and reflects our current understanding and recommendations for the diagnosis and management of portal hypertensive UGIB in Indians. Intended for use by the health care providers especially gastroenterologists and hepatologists, these consensus statements provide an evidence-based approach to risk stratification, diagnosis, and management of patients with portal hypertensive bleeding.
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Affiliation(s)
- Shivaram P Singh
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, 753 001, India.
| | - Manav Wadhawan
- Department of Hepatology and Liver Transplant, Institute of Liver and Digestive Diseases, BLK Super Specialty Hospital, Delhi, 110 005, India
| | - Subrat K Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, 751 024, India
| | - Sawan Bopanna
- Department of Gastroenterology and Hepatology, Fortis Flt. Lt. Rajan Dhall Hospital, Aruna Asaf Ali Marg, Vasant Kunj, New Delhi, 110 070, India
| | - Kaushal Madan
- Department of Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, 110 017, India
| | - Manoj K Sahoo
- Department of Medical Gastroenterology, IMS and SUM Hospital, K8 Kalinga Nagar, Shampur, Bhubaneswar, 751 003, India
| | - Naresh Bhat
- Department of Gastroenterology and Hepatology, Aster CMI Hospital, Bangalore, 560 092, India
| | - Sri P Misra
- Department of Gastroenterology and Hepatology, Moti Lal Nehru Medical College, Allahabad, 211 001, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
| | - Anil C Anand
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Patia, Bhubaneswar, 751 024, India
| | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India
| | | | - Joy Varghese
- Department of Hepatology and Transplant Hepatology, Institute of Liver Disease and Transplantation, Gleneagles Global Health City, 439, Cheran Nagar, Chennai, 600 100, India
| | - Manas K Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751 019, India
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, Hyderabad, 500 082, India
| | - Mihir K Mohapatra
- Department of Surgical Gastroenterology, Srirama Chandra Bhanja Medical College, Cuttack, 753 007, India
| | - Pankaj Puri
- Department of Gastroenterology and Hepatology, Fortis Escorts Liver and Digestive Diseases Institute, Okhla Road, New Delhi, 110 025, India
| | - Pravin M Rathi
- Department of Gastroenterology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, 400 008, India
| | - Rajkumar P Wadhwa
- Department of Gastroenterology, Apollo BGS Hospital, Adichuchanagiri Road, Kuvempunagar, Mysore, 570 023, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Varghese Thomas
- Department of Gastroenterology, Malabar Medical College Hospital, Modakkallur, Calicut, 673 321, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
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Hirsch BS, Ribeiro IB, Funari MP, de Moura DTH, Matuguma SE, Sánchez-Luna SA, Mancini FC, de Oliveira GHP, Bernardo WM, de Moura EGH. Endoscopic Band Ligation Versus Argon Plasma Coagulation in the Treatment of Gastric Antral Vascular Ectasia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Endosc 2021; 54:669-677. [PMID: 34053215 PMCID: PMC8505186 DOI: 10.5946/ce.2021.063] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/27/2021] [Accepted: 03/28/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND/AIMS Argon plasma coagulation (APC) is the most commonly used endoscopic treatment for gastric antral vascular ectasia (GAVE). Endoscopic band ligation (EBL) has emerged as an alternative therapy. Our goal was to evaluate the feasibility, efficacy, and safety of APC and EBL for the treatment of GAVE. This is the first systematic review that included only randomized controlled trials (RCTs) on this topic. METHODS A comprehensive search was performed using electronic databases to identify RCTs comparing APC and EBL for the treatment of GAVE following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS Four RCTs were included, with a total of 204 patients. EBL was related to higher endoscopic eradication rates risk difference [RD], 0.29; 95% confidence interval [CI] [0.14, 0.44]; I2=0%) and less bleeding recurrence than APC (RD, 0.29; 95% CI [0.15, 0.44]; I2=0%). Patients treated with EBL required fewer blood transfusions (mean difference [MD], 1.49; 95% CI [0.28, 2.71]; I2=96%) and hospitalizations (MD, 0.29; 95% CI [0.19, 0.39]; I2=0%). The number of sessions required for the obliteration of lesions was higher with APC. There was no difference in the incidence of adverse events. CONCLUSION EBL is superior to APC in the treatment of GAVE in terms of endoscopic eradication rates, recurrence of bleeding, and transfusion requirements.
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Affiliation(s)
- Bruno Salomão Hirsch
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Mateus Pereira Funari
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | | | - Sergio Eiji Matuguma
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Sergio A. Sánchez-Luna
- Center for Advanced Endoscopy, Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Department of Internal Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Fabio Catache Mancini
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
| | | | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, Brazil
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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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Kamezaki H, Naito T, Sekine Y, Maeda T, Senoo J, Sakamoto D. Lusutrombopag administration is effective for the hemostasis of intractable gastric antral vascular ectasia in a patient with liver cirrhosis. KANZO 2020; 61:520-526. [DOI: 10.2957/kanzo.61.520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Affiliation(s)
| | - Toshimasa Naito
- Department of Gastroenterology, Eastern Chiba Medical Center
| | - Yu Sekine
- Department of Gastroenterology, Eastern Chiba Medical Center
| | - Takahiro Maeda
- Department of Gastroenterology, Eastern Chiba Medical Center
| | - Junichi Senoo
- Department of Gastroenterology, Eastern Chiba Medical Center
| | - Dai Sakamoto
- Department of Gastroenterology, Eastern Chiba Medical Center
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Serling-Boyd N, Chung MPS, Li S, Becker L, Fernandez-Becker N, Clarke J, Fiorentino D, Chung L. Gastric antral vascular ectasia in systemic sclerosis: Association with anti-RNA polymerase III and negative anti-nuclear antibodies. Semin Arthritis Rheum 2020; 50:938-942. [PMID: 32906028 PMCID: PMC7584748 DOI: 10.1016/j.semarthrit.2020.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 06/16/2020] [Accepted: 06/30/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Gastric antral vascular ectasia (GAVE) is a vascular manifestation of systemic sclerosis (SSc) that can lead to iron deficiency anemia or acute gastrointestinal (GI) bleeding. We aimed to identify clinical features associated with GAVE. METHODS We performed a cohort study of SSc patients who were seen at Stanford between 2004 and 2018 and had undergone esophagogastroduodenoscopy (EGD). We compared the clinical features of those with and without GAVE, and multivariable logistic regression was performed to identify clinical correlates with GAVE. RESULTS A total of 225 patients with SSc who underwent EGD were included in this study and 19 (8.4%) had GAVE. Those with GAVE were more likely to have scleroderma renal crisis (SRC) (21% vs 3%; p < 0.01), positive anti-RNA polymerase III antibody (71% vs 19%; p < 0.01), nucleolar pattern of anti-nuclear antibody (ANA) (33% vs 11%; p=0.04), and negative ANA (<1:80 by immunofluorescence) (33% vs 11%; p=0.02). On multivariate analysis with multiple imputation, anti-RNA polymerase III positivity (OR 4.57; 95% CI (1.57 - 13.23), p < 0.01) and ANA negativity (OR 3.75; 95% CI (1.21 - 11.62), p=0.02) remained significantly associated with GAVE. CONCLUSION Positive anti-RNA polymerase III antibody and ANA negativity were significantly associated with GAVE. Further studies are necessary to determine whether patients with these autoantibody profiles should undergo screening endoscopies for GAVE.
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Affiliation(s)
- Naomi Serling-Boyd
- Department of Medicine, Division of Rheumatology, Allergy, & Immunology, Massachusetts General Hospital, USA
| | - Melody Pei-Shien Chung
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University School of Medicine, USA
| | - Shufeng Li
- Department of Dermatology, Stanford University School of Medicine, USA
| | - Laren Becker
- Department of Medicine, Division of Gastroenterology, Stanford University School of Medicine, USA
| | - Nielsen Fernandez-Becker
- Department of Medicine, Division of Gastroenterology, Stanford University School of Medicine, USA
| | - John Clarke
- Department of Medicine, Division of Gastroenterology, Stanford University School of Medicine, USA
| | - David Fiorentino
- Department of Dermatology, Stanford University School of Medicine, USA
| | - Lorinda Chung
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University School of Medicine, USA; Department of Medicine, Division of Immunology and Rheumatology, Palo Alto Veterans Affairs Healthcare System, USA.
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Magee C, Graham D, Leonard C, McMaster J, Davies H, Skotchko M, Lovat L, Murray C, Mealing S, Smart H, Haidry R. The cost-effectiveness of radiofrequency ablation for treating patients with gastric antral vascular ectasia refractory to first line endoscopic therapy. Curr Med Res Opin 2020; 36:977-983. [PMID: 32212980 DOI: 10.1080/03007995.2020.1747997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: This economic evaluation aims to provide a preliminary assessment of the cost-effectiveness of radiofrequency ablation (RFA) compared with argon plasma coagulation (APC) when used to treat APC-refractory gastric antral vascular ectasia (GAVE) in symptomatic patients.Methods: A Markov model was constructed to undertake a cost-utility analysis for adults with persistent symptoms secondary to GAVE refractory to first line endoscopic therapy. The economic evaluation was conducted from a UK NHS and personal social services (PSS) perspective, with a 20-year time horizon, comparing RFA with APC. Patients transfer between health states defined by haemoglobin level. The clinical effectiveness data were sourced from expert opinion, resource use and costs were reflective of the UK NHS and benefits were quantified using Quality Adjusted Life Years (QALYs) with utility weights taken from the literature. The primary output was the Incremental Cost-Effectiveness Ratio (ICER), expressed as cost per QALY gained.Results: Over a lifetime time horizon, the base case ICER was £4840 per QALY gained with an 82.2% chance that RFA was cost-effective at a threshold of £20,000 per QALY gained. The model estimated that implementing RFA would result in reductions in the need for intravenous iron, endoscopic intervention and requirement for blood transfusions by 27.1%, 32.3% and 36.5% respectively. Compared to APC, RFA was associated with an estimated 36.7% fewer procedures.Conclusions: RFA treatment is likely to be cost-effective for patients with ongoing symptoms following failure of first line therapy with APC and could lead to substantive reductions in health care resource.
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Affiliation(s)
- Cormac Magee
- Gastroenterology, University College Hospital, London, UK
| | - David Graham
- Gastroenterology, University College Hospital, London, UK
| | | | | | - Heather Davies
- York Health Economics Consortium, University of York, York, UK
| | - Maria Skotchko
- School of Health and Related Research (ScHARR), Sheffield University, Sheffield, UK
| | - Laurence Lovat
- Gastroenterology, University College Hospital, London, UK
| | - Charles Murray
- Gastroenterology, University College Hospital, London, UK
| | - Stuart Mealing
- York Health Economics Consortium, University of York, York, UK
| | - Howard Smart
- Gastroenterology and Hepatology, Royal Liverpool University Hospital, Liverpool, UK
| | - Rehan Haidry
- Gastroenterology, University College Hospital, London, UK
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Abstract
Complications of portal hypertension include portal hypertensive gastropathy and colopathy. These disorders may cause chronic or acute gastrointestinal bleeding. The diagnosis is made endoscopically; therefore, there is great variability in their assessment. Portal hypertensive gastropathy can range from a mosaic-like pattern resembling snakeskin mucosa to frankly bleeding petechial lesions. Portal hypertensive colopathy has been less well-described and is variably characterized (erythema, vascular lesions, petechiae). Treatment is challenging and results are inconsistent. Currently, available evidence does not support the use of beta-blockers for primary prevention. Further investigation of the pathogenesis, natural history, and treatment of these disorders is needed.
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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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Patel U, Desai R, Desai J, Damarlapally N, Zalavadia D, Yousef M, Coman R, Bansal P, Goyal H. Predictors of blood transfusion and in-hospital outcomes in patients with gastric antral vascular ectasia (GAVE): a nationwide population-based analysis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:46. [PMID: 30906750 DOI: 10.21037/atm.2019.01.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Gastric antral vascular ectasia (GAVE) is a rare cause of chronic non-variceal upper gastrointestinal (GI) bleeding and can turn into life-threatening bleed in some patients. Packed red blood cell (PRBC) transfusions are often required in these patients during hospitalization. We aimed to investigate the hospitalization outcomes and predictors of PRBC transfusions in patients with GAVE lesions. Methods Using the ICD-9-CM codes (537.82, 537.83), we queried the National Inpatient Sample (NIS) [2010-2014] to recognize hospitalized GAVE patients. A 1:2 random sample was obtained from the non-GAVE cohort and these groups were compared (GAVE vs. non-GAVE). The predictors of PRBC transfusion in GAVE cohort were analyzed with multivariate analysis by using SPSS Statistics 22.0. Results We included weighted 89,081 GAVE and 178,550 non-GAVE hospitalized patients. The GAVE patients were tended to be older, female and white. Significantly higher proportions of comorbidities such as congestive heart failure, diabetes, hypertension, hypothyroidism, liver disease, renal failure, Sjogren syndrome, systemic sclerosis and portal hypertension, etc. were present in these patients. The all-cause inpatient mortality was found to be 1.4%. The mean hospital charges and length of stay (LOS) per GAVE hospitalization were $36,059 and 4.63±5.3 days, respectively. A total of 6,276 (weighted 31,102) (34.9%) of these patients received at least one PRBC transfusion during hospitalization. Advanced age, multiple comorbidities, non-elective admissions, male gender, and African American race were the independent factors associated with higher chances of receiving PRBC transfusion. Conclusions Our analysis showed that hospitalized patients with GAVE lesions had lower overall mortality rate despite having multiple comorbidities. There was no difference in the LOS and hospital charges between the two cohorts. Nearly 35% of the GAVE patients received at least one PRBC transfusion.
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Affiliation(s)
- Upenkumar Patel
- Division of Internal Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | | | - Jiten Desai
- Division of Internal Medicine, Nassau University Medical Center, East Meadow, NY, USA
| | - Nanush Damarlapally
- Department of Health Sciences, Coleman College of Health Sciences, Houston, TX, USA
| | - Dipen Zalavadia
- Division of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | - Mohamad Yousef
- Division of Gastroenterology and Hepatology, University of Missouri at Columbia, Columbia, MO, USA
| | - Roxana Coman
- Division of Gastroenterology, Medical Center Navicent Health, Macon, GA, USA
| | - Pardeep Bansal
- Department of Gastroenterology, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | - Hemant Goyal
- Department of Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
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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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Żorniak M, Garczorz W, Wosiewicz P, Marek T, Błaszczyńska M, Waluga M, Kukla M, Kimsa-Furdzik M, Francuz T, Hartleb M. Mucosal miR-3677 is over-expressed in cirrhotic patients with gastric antral vascular ectasia (GAVE). Scand J Gastroenterol 2018; 53:1503-1508. [PMID: 30621516 DOI: 10.1080/00365521.2018.1547922] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Gastric antral vascular ectasia (GAVE) is a rare vasculopathy that associates several diseases, most commonly liver cirrhosis. It usually presents as an occult gastrointestinal bleeding leading to profound iron deficiency anemia. We hypothesized that GAVE is local mucosal pathology dependent on genetic mechanisms, and the purpose of the study was to characterize miRNAs expression in gastric tissue of patients with cirrhosis and GAVE. MATERIALS AND METHODS Thirteen patients with GAVE and cirrhosis and 35 healthy subjects were recruited. Microarray analysis and comparative microRNA study was done by quantitative polymerase chain reaction (qPCR). The microarray scores were grouped with use of the hierarchical clusterization analysis and miRNA target prediction was done with TargetScan 6.2 algorithm and Gene Ontology analysis (DIANA-miRPath). RESULTS Concentration of miR-3677 in GAVE-affected mucosa was higher by 72% in comparison with GAVE-free mucosa of patients with cirrhosis (33.7 vs. 35.6 PCR cycles; p < .001) and by 45% in comparison with normal mucosa (33.7 vs. 34.9 PCR cycles; p < .05). According to Gene Ontology analysis miR-3677 was related to angiopoietin-like protein 4 (ANGPTL4) gene. CONCLUSION GAVE in liver cirrhosis is associated with increased expression of miR-3667 that may be linked with ANGPTL4 gene.
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Affiliation(s)
- Michał Żorniak
- a Department of Gastroenterology and Hepatology , School of Medicine in Katowice, Medical University of Silesia , Katowice , Poland
| | - Wojciech Garczorz
- b Department of Biochemistry, School of Medicine in Katowice , Medical University of Silesia , Katowice , Poland
| | - Piotr Wosiewicz
- a Department of Gastroenterology and Hepatology , School of Medicine in Katowice, Medical University of Silesia , Katowice , Poland
| | - Tomasz Marek
- a Department of Gastroenterology and Hepatology , School of Medicine in Katowice, Medical University of Silesia , Katowice , Poland
| | | | - Marek Waluga
- a Department of Gastroenterology and Hepatology , School of Medicine in Katowice, Medical University of Silesia , Katowice , Poland
| | - Michał Kukla
- a Department of Gastroenterology and Hepatology , School of Medicine in Katowice, Medical University of Silesia , Katowice , Poland
| | - Małgorzata Kimsa-Furdzik
- b Department of Biochemistry, School of Medicine in Katowice , Medical University of Silesia , Katowice , Poland
| | - Tomasz Francuz
- b Department of Biochemistry, School of Medicine in Katowice , Medical University of Silesia , Katowice , Poland
| | - Marek Hartleb
- a Department of Gastroenterology and Hepatology , School of Medicine in Katowice, Medical University of Silesia , Katowice , Poland
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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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HSCT-GAVE as a Manifestation of Chronic Graft versus Host Disease: A Case Report and Review of the Existing Literature. Case Rep Transplant 2018; 2018:2376483. [PMID: 29721346 PMCID: PMC5867646 DOI: 10.1155/2018/2376483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 02/05/2018] [Accepted: 02/08/2018] [Indexed: 11/17/2022] Open
Abstract
Gastric antral vascular ectasia or “watermelon stomach” is a significant cause of nonvariceal upper GI bleeding and is characterized by red, tortuous ectatic vessels along longitudinal folds in the gastric antrum. The existing literature links GAVE to patients with cirrhosis, scleroderma, bone marrow transplantation, and chronic renal failure among other associations, but its pathophysiology remains ill-defined. Over 30 cases of hematopoietic stem cell transplant-related GAVE (HSCT-GAVE) have been reported in the literature to date and there are likely many more that go undiagnosed or are attributed to another cause of upper gastrointestinal bleeding. Interestingly, a busulfan-containing conditioning regimen has been the primary factor implicated in the etiology of HSCT-GAVE because this was common to all cases in the literature to date. Here, we present the first case of HSCT-GAVE in a patient that was treated with a non-busulfan-containing conditioning regimen. We propose a link between chronic GVHD and the development of HSCT-GAVE that is supported by a similar development of GAVE in patients with systemic sclerosis.
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Thomas A, Koch D, Marsteller W, Lewin D, Reuben A. An Analysis of the Clinical, Laboratory, and Histological Features of Striped, Punctate, and Nodular Gastric Antral Vascular Ectasia. Dig Dis Sci 2018; 63:966-973. [PMID: 29450749 DOI: 10.1007/s10620-018-4965-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/03/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) commonly presents as linear striped ("watermelon stomach") or punctate phenotypes, to which a newly discovered nodular form was recently added. AIMS We performed a retrospective cohort study to detail and compare the clinical and histological characteristics of major GAVE phenotypes. METHODS In 136 GAVE patients (tertiary care ambulatory and inpatient, median age 61.3 years, 73 men, and 63 women), clinical and laboratory results were recorded, with comorbidities, endoscopy indications, and complications of cirrhosis. In 74 patients, GAVE histopathology was cataloged by a pathologist masked to endoscopy results. RESULTS Median age 61.3 years, 73 men, and 63 women. GAVE phenotypes were: linear striped-62 (46%), punctate-32 (24%), and nodular-41 (30%). Endoscopy was commonly performed for variceal screening in linear striped (45%) and nodular (34%) GAVE and for gastrointestinal bleeding in punctate (41%) and nodular (29%) GAVE, respectively. Of 89 cirrhotic patients, 37.5% each had linear striped or nodular GAVE, 24.7% had punctate forms (p = 0.03). Child-Turcotte-Pugh and Model for End-Stage Liver Disease scores were similar among phenotypes. Histologically, reactive epithelial hyperplasia and vascular ectasia were universal; smooth muscle proliferation was more common and consistent (78-86%) than microvascular thrombi (27-59%) and fibrohyalinosis (18-53%), which each varied with phenotype. CONCLUSIONS Nodular GAVE is a gastric mucosal abnormality that is similar to the linear striped and punctate phenotypes, yet has distinct clinical and histological features. Increased awareness of nodular GAVE by endoscopists is needed to avoid its misdiagnosis as nonspecific antral nodules.
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Affiliation(s)
- Arul Thomas
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, 20007, USA
| | - David Koch
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA.
| | - William Marsteller
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - David Lewin
- Department of Pathology, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Adrian Reuben
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
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St Romain P, Boyd A, Zheng J, Chow SC, Burbridge R, Wild D. Radiofrequency ablation (RFA) vs. argon plasma coagulation (APC) for the management of gastric antral vascular ectasia (GAVE) in patients with and without cirrhosis: results from a retrospective analysis of a large cohort of patients treated at a single center. Endosc Int Open 2018; 6:E266-E270. [PMID: 29497685 PMCID: PMC5829995 DOI: 10.1055/s-0043-123187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/08/2017] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION AND STUDY AIMS Gastric antral vascular ectasia (GAVE) is a mucosal abnormality associated with multiple conditions, most notably cirrhosis and systemic sclerosis, that causes indolent gastrointestinal bleeding. It is primarily managed with endoscopic therapy. Traditionally, GAVE is endoscopically ablated using argon plasma coagulation (APC) but radiofrequency ablation (RFA) is emerging as an alternative modality. No prior comparison of the 2 modalities has been published. PATIENTS AND METHODS After receiving IRB approval, we reviewed our electronic health records to identify all patients who underwent endoscopic evaluation for GAVE between January, 2011 and October, 2016. We compared important variables between APC and RFA, as well as between cirrhosis and non-cirrhosis, using the Chi-square test and the Wilcoxon two-sample test as appropriate. RESULTS During our study period, 81 patients were endoscopically evaluated for GAVE. 24 patients were treated with APC alone, 28 with RFA alone and 25 patients received both treatment modalities. CONCLUSIONS RFA and APC were both effective in treating bleeding from GAVE. Though we found subtle differences, patients underwent a similar number of treatment sessions and had similar procedure times and a similar time between sessions no matter the treatment modality used.
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Affiliation(s)
- Paul St Romain
- Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina, United States,Corresponding author Paul St. Romain Duke University Medical CenterDepartment of Medicine, Division of Gastroenterology03142 Orange ZoneDurham, NC 27710+1-919-684-8857
| | - Amanda Boyd
- Division of Internal Medicine, Duke University Medical Center, Durham, North Carolina, United States
| | - Jiayin Zheng
- Division of Biostatistics, Duke University Medical Center, Durham, North Carolina, United States
| | - Shein-Chung Chow
- Division of Biostatistics, Duke University Medical Center, Durham, North Carolina, United States
| | - Rebecca Burbridge
- Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina, United States
| | - Daniel Wild
- Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina, United States
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Hsu WH, Wang YK, Hsieh MS, Kuo FC, Wu MC, Shih HY, Wu IC, Yu FJ, Hu HM, Su YC, Wu DC. Insights into the management of gastric antral vascular ectasia (watermelon stomach). Therap Adv Gastroenterol 2018; 11:1756283X17747471. [PMID: 29399041 PMCID: PMC5788127 DOI: 10.1177/1756283x17747471] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/30/2017] [Indexed: 02/04/2023] Open
Abstract
Gastric antral vascular ectasia (GAVE) is an uncommon but important cause of chronic gastrointestinal bleeding. It is often associated with systemic diseases such as autoimmune diseases, liver cirrhosis, chronic renal insufficiency and cardiovascular disease. The etiology of GAVE has not been fully explored and remains controversial. Diagnosis is mainly based on endoscopic presentation with flat or raised erythematous stripes radiating from the pylorus to the antrum and resembles a watermelon. Clinical presentation may range from iron-deficiency anemia secondary to occult blood loss, melena to hematemesis. In past decades, many therapeutic modalities including medical, endoscopic and surgical intervention have been introduced for GAVE treatment with variable efficacy. Herein, we review the efficacy and safety of these treatment options for GAVE.
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Affiliation(s)
- Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yao-Kuang Wang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
| | - Meng-Shu Hsieh
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Fu-Chen Kuo
- Shool of Medicine, College of Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Meng-Chieh Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Hsiang-Yao Shih
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - I-Chen Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Fang-Jung Yu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Huang-Ming Hu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Chung Su
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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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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Gkamprela E, Deutsch M, Pectasides D. Iron deficiency anemia in chronic liver disease: etiopathogenesis, diagnosis and treatment. Ann Gastroenterol 2017; 30:405-413. [PMID: 28655976 PMCID: PMC5479992 DOI: 10.20524/aog.2017.0152] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 03/21/2017] [Indexed: 12/21/2022] Open
Abstract
Chronic liver disease is accompanied by multiple hematological abnormalities. Iron deficiency anemia is a frequent complication of advanced liver disease. The etiology is multifactorial, mostly due to chronic hemorrhage into the gastrointestinal tract. The diagnosis of iron deficiency anemia is very challenging, as simple laboratory methods, including serum iron, ferritin, transferrin saturation (Tsat), and mean corpuscular volume are affected by the liver disease itself or the cause of the disease, resulting in difficulty in the interpretation of the results. Several new parameters, such as red blood cell ferritin, serum transferrin receptor test and index, and hepcidin, have been studied for their utility in indicating true iron deficiency in combination with chronic liver disease. Once iron deficiency anemia is diagnosed, it should be treated with oral or parenteral iron as well as portal pressure reducing drugs. Blood transfusion is reserved for symptomatic anemia despite iron supplementation.
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Affiliation(s)
- Eleana Gkamprela
- Second Department of Internal Medicine, University of Athens, Hippokration General Hospital, Athens
| | - Melanie Deutsch
- Second Department of Internal Medicine, University of Athens, Hippokration General Hospital, Athens
| | - Dimitrios Pectasides
- Second Department of Internal Medicine, University of Athens, Hippokration General Hospital, Athens
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Fagiuoli S, Bruno R, Debernardi Venon W, Schepis F, Vizzutti F, Toniutto P, Senzolo M, Caraceni P, Salerno F, Angeli P, Cioni R, Vitale A, Grosso M, De Gasperi A, D'Amico G, Marzano A. Consensus conference on TIPS management: Techniques, indications, contraindications. Dig Liver Dis 2017; 49:121-137. [PMID: 27884494 DOI: 10.1016/j.dld.2016.10.011] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/27/2016] [Accepted: 10/17/2016] [Indexed: 12/11/2022]
Abstract
The trans jugular intrahepatic Porto systemic shunt (TIPS) is no longer viewed as a salvage therapy or a bridge to liver transplantation and is currently indicated for a number of conditions related to portal hypertension with positive results in survival. Moreover, the availability of self-expandable polytetrafluoroethylene (PTFE)-covered endoprostheses has dramatically improved the long-term patency of TIPS. However, since the last updated International guidelines have been published (year 2009) new evidence have come, which have open the field to new indications and solved areas of uncertainty. On this basis, the Italian Association of the Study of the Liver (AISF), the Italian College of Interventional Radiology-Italian Society of Medical Radiology (ICIR-SIRM), and the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) promoted a Consensus Conference on TIPS. Under the auspices of the three scientific societies, the consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Bergamo on June 4th and 5th, 2015. The final statements presented here were graded according to quality of evidence and strength of recommendations and were approved by an independent jury. By highlighting strengths and weaknesses of current indications to TIPS, the recommendations of AISF-ICIR-SIRM-SIAARTI may represent the starting point for further studies.
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Affiliation(s)
- Stefano Fagiuoli
- Gastroenterologia Epatologia e Trapiantologia, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Raffaele Bruno
- Dept. of Infectious Diseases, Hepatology Outpatients Unit, University of Pavia-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Wilma Debernardi Venon
- Gastroepatologia, AOU Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
| | - Filippo Schepis
- Department of Gastroenterology University of Modena and Reggio Emilia, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Pierluigi Toniutto
- Medical Liver Transplant Section, Department of Medical Sciences Experimental and Clinical, Internal Medicine, University of Udine, Italy
| | - Marco Senzolo
- Unità di Trapianto Multiviscerale, Gastroenterologia, Dipartimento di Scienze Chirurgiche e Gastroenterologiche, Università-Ospedale di Padova, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Francesco Salerno
- Department of Internal Medicine, Policlinico IRCCS San Donato, University of Milan, Italy
| | - Paolo Angeli
- Internal Medicine and Hepatology Department of Medicine (DIMED), University of Padova, Italy
| | - Roberto Cioni
- Dipartimento di Radiologia Diagnostica e Interventistica, UO di Radiologia Interventistica, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Alessandro Vitale
- U.O.C. di Chirurgia Epatobiliare e del Trapianto Epatico, Azienda Ospedaliera Università di Padova, Italy
| | - Maurizio Grosso
- Department of Radiology S. Croce and Carle Hospital Cuneo, Italy
| | - Andrea De Gasperi
- 2° Servizio Anestesia e Rianimazione-Ospedale Niguarda Ca Granda, Milan, Italy
| | | | - Alfredo Marzano
- Gastroepatologia, AOU Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
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Zepeda-Gómez S. Endoscopic Treatment for Gastric Antral Vascular Ectasia: Current Options. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 24:176-182. [PMID: 29255747 DOI: 10.1159/000453271] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/04/2016] [Indexed: 01/10/2023]
Abstract
Gastric antral vascular ectasia (GAVE) is a capillary-type vascular malformation located primarily in the gastric antrum. Patients can present with iron-deficiency anemia, overt gastrointestinal bleeding, or both. Diagnosis and characterization is made at endoscopic examination, and the preferred management of patients with GAVE is endoscopic therapy. Herein, we present a review of the evidence about the efficacy, complications, and outcomes of the most frequently used endoscopic therapies for GAVE.
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Licinio R, Losurdo G, Carparelli S, Iannone A, Giorgio F, Barone M, Principi M, Ierardi E, Di Leo A. Helicobacter pylori, liver cirrhosis, and portal hypertension: an updated appraisal. Immunopharmacol Immunotoxicol 2016; 38:408-413. [PMID: 27788611 DOI: 10.1080/08923973.2016.1247855] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 10/06/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Helicobacter pylori (H. pylori) is the most common cause of gastritis and peptic ulcer. However, H. pylori is even involved in extragastric diseases, and it has been hypothesized that H. pylori could be a risk factor for several hepatic diseases. For instance, a direct involvement of H. pylori in the development of portal hypertension (PH) in cirrhotic patients has been postulated. METHODS We performed a literature search in major databases to elucidate the relationship between H. pylori, portal hypertension, and liver cirrhosis. RESULTS The effect of H. pylori on PH may be multifactorial. Endothelial dysfunction, alterations in the vasodilating dynamics, and neoangiogenesis are the most appealing theories about this issue, but the proofs come mainly from experimental studies, therefore a solid pathophysiological basis is still to be demonstrated. Congestive gastropathy (CG) and gastric antral vascular ectasia (GAVE) are two common endoscopic entities responsible for acute/chronic upper gastrointestinal bleeding, and a link with H. pylori has been hypothesized: the gastric mucosa, exposed to H. pylori, could develop both inflammatory microcirculatory alterations and thrombi, resembling the histologic pattern of GAVE. CONCLUSIONS Despite clues for an association between H. pylori and PH have been shown, these evidences are mostly experimental, therefore, in the absence of a direct proof on human beings, the role of H. pylori in the development of PH is uncertain. However, since this germ may be a cause of peptic ulcer, it should be found and eradicated in cirrhotic patients to reduce the risk of blood loss anemia.
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Affiliation(s)
- Raffaele Licinio
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Giuseppe Losurdo
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Sonia Carparelli
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Andrea Iannone
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Floriana Giorgio
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Michele Barone
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Mariabeatrice Principi
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Enzo Ierardi
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
| | - Alfredo Di Leo
- a Department of Emergency and Organ Transplantation , Section of Gastroenterology, AOU Policlinico , Bari , Italy
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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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Primignani M, Tosetti G. Portal hypertensive gastropathy after variceal eradication: more bleeding risk or just more reddening? Hepatol Int 2016; 10:847-850. [PMID: 27282878 DOI: 10.1007/s12072-016-9750-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Massimo Primignani
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giulia Tosetti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Allaire M, Nault JC, Sutter O, Nahon P, Amathieu R. Traitement des complications de l’hypertension portale par TIPS en 2016. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1211-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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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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Abstract
PURPOSE OF REVIEW Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are two types of upper gastrointestinal bleeding that may present similarly, but are managed very differently. This article reviews the pathogenesis and guidelines in management of both of these conditions with emphasis on recent advances in the field. RECENT FINDINGS Off-label use of Hemospray has been shown in several case series to be useful in managing acute bleeding from PHG. Balloon-occluded retrograde transvenous obliteration presents an alternative approach for this condition. Radiofrequency ablation may be an alternative therapy to argon plasma coagulation in the endoscopic treatment of GAVE, as it consists of fewer sessions and has been shown to decrease gastrointestinal blood loss. SUMMARY The treatment options for PHG and GAVE are constantly evolving and expanding. In this review, we present the latest approaches in the gastroenterologist's arsenal to deal with these conditions.
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Garg H, Gupta S, Anand AC, Broor SL. Portal hypertensive gastropathy and gastric antral vascular ectasia. Indian J Gastroenterol 2015; 34:351-8. [PMID: 26564121 DOI: 10.1007/s12664-015-0605-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 10/17/2015] [Indexed: 02/04/2023]
Abstract
Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are gastric mucosal lesions that mostly present as chronic anemia and rarely cause the acute gastrointestinal hemorrhage. Despite similar clinical manifestations, their pathophysiology and management are entirely different. PHG is seen exclusively in patients with portal hypertension, but GAVE can also be observed in patients with other conditions. Their diagnosis is endoscopic, and although generally each of them has a characteristic endoscopic appearance and distribution, there are cases in which the differential is difficult and must rely on histology. This review focuses on the management of both entities. The mainstay of management of PHG is based on portal-hypotensive pharmacological treatment while GAVE benefits from hormonal therapy, endoscopic Nd:YAG laser, and argon plasma coagulation. More invasive options should be reserved for refractory cases.
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Affiliation(s)
- Hitendra Garg
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India.
| | - Subhash Gupta
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India
| | - A C Anand
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India
| | - S L Broor
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India.,Gastroenterology and Hepatology, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India
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Becq A, Camus M, Rahmi G, de Parades V, Marteau P, Dray X. Emerging indications of endoscopic radiofrequency ablation. United European Gastroenterol J 2015; 3:313-24. [PMID: 26279839 DOI: 10.1177/2050640615571159] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 01/12/2015] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Radiofrequency ablation (RFA) is a well-validated treatment of dysplastic Barrett's esophagus. Other indications of endoscopic RFA are under evaluation. RESULTS Four prospective studies (total 69 patients) have shown that RFA achieved complete remission of early esophageal squamous intra-epithelial neoplasia at a rate of 80%, but with a substantial risk of stricture. In the setting of gastric antral vascular ectasia, two prospective monocenter studies, and a retrospective multicenter study, (total 51 patients), suggest that RFA is efficacious in terms of reducing transfusion dependency. In the setting of chronic hemorrhagic radiation proctopathy, a prospective monocenter study and a retrospective multicenter study (total 56 patients) suggest that RFA is an efficient treatment. A retrospective comparative study (64 patients) suggests that RFA improves stents patency in malignant biliary strictures. CONCLUSIONS Endoscopic RFA is an upcoming treatment modality in early esophageal squamous intra-epithelial neoplasia, as well as in gastric, rectal, and biliary diseases.
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Affiliation(s)
- Aymeric Becq
- Department of Gastroenterology and Hepatology, Sorbonne Paris Cité Paris 7 University & APHP Lariboisière Hospital, Paris, France
| | - Marine Camus
- Department of Gastroenterology and Hepatology, Sorbonne Paris Cité Paris 7 University & APHP Lariboisière Hospital, Paris, France
| | - Gabriel Rahmi
- Department of Gastroenterology and Hepatology, Sorbonne Paris Cité Paris 5 University & APHP, European Georges Pompidou Hospital, Paris, France
| | - Vincent de Parades
- Department of Medicosurgical Proctology, Léopold Bellan Institute, Saint Joseph Hospital, Paris, France
| | - Philippe Marteau
- Department of Gastroenterology and Hepatology, Sorbonne Paris Cité Paris 7 University & APHP Lariboisière Hospital, Paris, France
| | - Xavier Dray
- Department of Gastroenterology and Hepatology, Sorbonne Paris Cité Paris 7 University & APHP Lariboisière Hospital, Paris, France
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44
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[Watermelon stomach: Chronic renal failure and/or imatinib?]. Nephrol Ther 2015; 11:496-501. [PMID: 26165799 DOI: 10.1016/j.nephro.2015.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/13/2015] [Indexed: 02/07/2023]
Abstract
Watermelon stomach or gastric antral vascular ectasia (GAVE) syndrome is an uncommon cause of sometimes severe upper gastro-intestinal bleeding. Essentially based on a pathognomonic endoscopic appearance, its diagnosis may be unrecognised because mistaken with portal hypertensive gastropathy, while treatment of these two entities is different. Its etiopathogeny remains still unclear, even if it is frequently associated with different systemic illnesses as hepatic cirrhosis, autoimmune disorders and chronic renal failure. The mechanism inducing these vascular ectasia may be linked with mechanical stress on submucosal vessels due to antropyloric peristaltic motility dysfunction modulated by neurohormonal vasoactive alterations. Because medical therapies are not very satisfactory, among the endoscopic modalities, argon plasma coagulation seems to be actually the first-line treatment because the most effective and safe. However, surgical antrectomy may be sometimes necessary. Recently GAVE syndrome appeared as a new adverse reaction of imatinib mesylate, one of the tyrosine kinase inhibitors used in chronic myeloid leukemia, and we report here the observation of such a pathology in one patient treated at the same time by haemodialysis and by imatinib mesylate for chronic myeloid leukemia.
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Parikh K, Ali MA, Wong RCK. Unusual Causes of Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2015; 25:583-605. [PMID: 26142040 DOI: 10.1016/j.giec.2015.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Upper gastrointestinal (GI) bleeding is an important clinical condition managed routinely by endoscopists. Diagnostic and therapeutic options vary immensely based on the source of bleeding and it is important for the gastroenterologist to be cognizant of both common and uncommon etiologies. The focus of this article is to highlight and discuss unusual sources of upper GI bleeding, with a particular emphasis on both the clinical and endoscopic features to help diagnose and treat these atypical causes of bleeding.
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Affiliation(s)
- Keyur Parikh
- Digestive Health Institute, Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA
| | - Meer Akbar Ali
- Digestive Health Institute, Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA
| | - Richard C K Wong
- Digestive Health Institute, Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5066, USA.
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Loffroy R, Favelier S, Pottecher P, Estivalet L, Genson PY, Gehin S, Krausé D, Cercueil JP. Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: Indications, techniques and outcomes. Diagn Interv Imaging 2015; 96:745-55. [PMID: 26094039 DOI: 10.1016/j.diii.2015.05.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 05/19/2015] [Indexed: 12/19/2022]
Abstract
Acute variceal bleeding is a life-threatening condition that requires a multidisciplinary approach for effective therapy. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute bleeding. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy fail, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This procedure involves establishment of a direct pathway between the hepatic veins and the portal veins to decompress the portal venous hypertension that is the source of the patient's bleeding. The procedure is technically challenging, especially in critically ill patients, and has a mortality of 30%-50% in the emergency setting, but has an effectiveness greater than 90% in controlling bleeding from gastro-esophageal varices. This review focuses on the role of TIPS in the setting of variceal bleeding, with emphasis on current indications and techniques for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolization of varices.
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Affiliation(s)
- R Loffroy
- Department of vascular, oncologic and interventional radiology, Le2i UMR CNRS 6306, University of Dijon School of Medicine, Bocage Teaching Hospital, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France.
| | - S Favelier
- Department of vascular, oncologic and interventional radiology, Le2i UMR CNRS 6306, University of Dijon School of Medicine, Bocage Teaching Hospital, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France
| | - P Pottecher
- Department of vascular, oncologic and interventional radiology, Le2i UMR CNRS 6306, University of Dijon School of Medicine, Bocage Teaching Hospital, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France
| | - L Estivalet
- Department of vascular, oncologic and interventional radiology, Le2i UMR CNRS 6306, University of Dijon School of Medicine, Bocage Teaching Hospital, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France
| | - P Y Genson
- Department of vascular, oncologic and interventional radiology, Le2i UMR CNRS 6306, University of Dijon School of Medicine, Bocage Teaching Hospital, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France
| | - S Gehin
- Department of vascular, oncologic and interventional radiology, Le2i UMR CNRS 6306, University of Dijon School of Medicine, Bocage Teaching Hospital, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France
| | - D Krausé
- Department of vascular, oncologic and interventional radiology, Le2i UMR CNRS 6306, University of Dijon School of Medicine, Bocage Teaching Hospital, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France
| | - J-P Cercueil
- Department of vascular, oncologic and interventional radiology, Le2i UMR CNRS 6306, University of Dijon School of Medicine, Bocage Teaching Hospital, 14, rue Paul-Gaffarel, BP 77908, 21079 Dijon cedex, France
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Becq A, Ozenne V, Plessier A, Valleur P, Dray X. Transjugular intrahepatic portosystemic shunt as bridge-to-surgery in refractory gastric antral vascular ectasia. World J Gastroenterol 2015; 21:5749-5750. [PMID: 25987803 PMCID: PMC4427702 DOI: 10.3748/wjg.v21.i18.5749] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 01/23/2015] [Accepted: 02/11/2015] [Indexed: 02/06/2023] Open
Abstract
Gastric antral vascular ectasia (GAVE) may cause gastrointestinal bleeding (GIB). The treatment of GAVE relies on endoscopic approaches such as electrocoagulation (argon plasma coagulation, laser therapy, heater probe therapy, radiofrequency ablation), cryotherapy, and band ligation. In refractory cases, antrectomy may be considered. In the event of an associated cirrhosis and portal hypertension, it has been suggested that antrectomy could be an option, provided the mortality risk isn't considered too great. We report the case of a 67-year-old cirrhotic patient who presented with GAVE related GIB, unresponsive to multiple endoscopic treatments. The patient had a good liver function (model for end-stage disease 10). After a multidisciplinary meeting, a transjugular intrahepatic portosystemic shunt (TIPS) procedure was performed, in order to treat the cirrhosis associated ascites. The outcome was successful. An antrectomy was then performed, with no recurrence of GIB and no transfusion need during three months of follow up. In this case, the TIPS procedure achieved a complete ascites regression, allowing a safer surgical treatment of the GAVE-related GIB.
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Becq A, Camus M, Rahmi G, Parades VD, Laquière A, Boustière C, Marteau P, Dray X. Indications émergentes de la radiofréquence endoscopique. ACTA ENDOSCOPICA 2015; 45:122-131. [DOI: 10.1007/s10190-015-0437-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2025]
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Lesiones vasculares gástricas en la cirrosis: gastropatía y ectasia vascular antral. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:97-107. [DOI: 10.1016/j.gastrohep.2014.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/12/2014] [Accepted: 10/27/2014] [Indexed: 02/08/2023]
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Siramolpiwat S. Transjugular intrahepatic portosystemic shunts and portal hypertension-related complications. World J Gastroenterol 2014; 20:16996-17010. [PMID: 25493012 PMCID: PMC4258568 DOI: 10.3748/wjg.v20.i45.16996] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 07/09/2014] [Accepted: 08/28/2014] [Indexed: 02/06/2023] Open
Abstract
Portal hypertension (PH) plays an important role in the natural history of cirrhosis, and is associated with several clinical consequences. The introduction of transjugular intrahepatic portosystemic shunts (TIPS) in the 1980s has been regarded as a major technical advance in the management of the PH-related complications. At present, polytetrafluoroethylene-covered stents are the preferred option over traditional bare metal stents. TIPS is currently indicated as a salvage therapy in patients with bleeding esophageal varices who fail standard treatment. Recently, applying TIPS early (within 72 h after admission) has been shown to be an effective and life-saving treatment in those with high-risk variceal bleeding. In addition, TIPS is recommended as the second-line treatment for secondary prophylaxis. For bleeding gastric varices, applying TIPS was able to achieve hemostasis in more than 90% of patients. More trials are needed to clarify the efficacy of TIPS compared with other treatment modalities, including cyanoacrylate injection and balloon retrograde transvenous obliteration of gastric varices. TIPS should also be considered in bleeding ectopic varices and refractory portal hypertensive gastropathy. In patients with refractory ascites, there is growing evidence that TIPS not only results in better control of ascites, but also improves long-term survival in appropriately selected candidates. In addition, TIPS is a promising treatment for refractory hepatic hydrothorax. However, the role of TIPS in the treatment of hepatorenal and hepatopulmonary syndrome is not well defined. The advantage of TIPS is offset by a risk of developing hepatic encephalopathy, the most relevant post-procedural complication. Emerging data are addressing the determination the optimal time and patient selection for TIPS placement aiming at improving long-term treatment outcome. This review is aimed at summarizing the published data regarding the application of TIPS in the management of complications related to PH.
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