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Argon photocoagulation in the treatment of gastric antral vascular ectasia and radiation proctitis. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2010; 23:801-4. [PMID: 20011731 DOI: 10.1155/2009/374138] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Gastric antral vascular ectasia (GAVE) and radiation proctitis are two vascular disorders of the gastrointestinal tract that typically present with recurrent gastrointestinal bleeding. Although the pathogenesis of either condition is not known, they are unlikely to be similar. GAVE appears to be related to autoimmune disorders or cirrhosis, while radiation proctitis is the result of pelvic irradiation, most commonly used for the treatment of pelvic malignancies. Medical therapies for both conditions are not typically effective, and surgical therapies are usually not required because endoscopic treatment, aimed at coagulation of the underlying vascular lesions, has evolved as the most effective therapy. There is limited evidence in the literature for the use of medical and surgical therapies, with most of the evidence coming from case reports involving small numbers of patients. In the present article, we review the evidence for the use of argon plasma photocoagulation (APC, the most commonly used endoscopic modality) in the treatment of GAVE and radiation proctitis.
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Choe WH. Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 56:186-91. [DOI: 10.4166/kjg.2010.56.3.186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Won Hyeok Choe
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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53
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Tetart F, Lorthioir A, Girszyn N, Lahaxe L, Ducrotté P, Marie I. Watermelon stomach revealing generalized essential telangiectasia. Intern Med J 2009; 39:781-3. [PMID: 19912409 DOI: 10.1111/j.1445-5994.2009.02048.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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54
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Laparoscopic Surgical Treatment for Refractory Gastric Antral Vascular Ectasia. Surg Laparosc Endosc Percutan Tech 2009; 19:e189-93. [DOI: 10.1097/sle.0b013e3181bb5a19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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55
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Schulz SW, O'Brien M, Maqsood M, Sandorfi N, Del Galdo F, Jimenez SA. Improvement of severe systemic sclerosis-associated gastric antral vascular ectasia following immunosuppressive treatment with intravenous cyclophosphamide. J Rheumatol 2009; 36:1653-6. [PMID: 19605670 DOI: 10.3899/jrheum.081247] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE We describe 3 patients with systemic sclerosis (SSc) with severe, transfusion-dependent gastric antral vascular ectasia (GAVE) refractory to laser ablation who showed remarkable clinical and endoscopic improvement following intravenous (IV) pulse cyclophosphamide (CYC) treatment. METHODS Review of clinical records and upper gastrointestinal endoscopy images from 3 patients with SSc and severe GAVE before and after treatment with IV pulse CYC. RESULTS IV CYC was followed by improvement and stabilization of hemoglobin levels, and marked reduction in blood transfusion requirements and the number and frequency of endoscopic laser treatments. CONCLUSION IV pulse CYC immunosuppression was followed by remarkable clinical and endoscopic improvement of SSc-associated GAVE.
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Affiliation(s)
- Steffan W Schulz
- Jefferson Institute of Molecular Medicine, Division of Connective Tissue Disease, Department of Dermatology and CutaneousBiology, Division of Rheumatology, Thomas Jefferson University, Philadelphia, Pennsylvania; and Division of Rheumatology, Lehigh ValleyHospital, Allentown, Pennsylvania, USA
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Yamamoto M, Takahashi H, Akaike J, Suzuki C, Naishiro Y, Yamamoto H, Imai K, Shinomura Y. Gastric antral vascular ectasia (GAVE) associated with systemic sclerosis. Scand J Rheumatol 2009; 37:315-6. [DOI: 10.1080/03009740801998754] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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57
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Forbes A, Marie I. Gastrointestinal complications: the most frequent internal complications of systemic sclerosis. Rheumatology (Oxford) 2009; 48 Suppl 3:iii36-9. [PMID: 19487222 DOI: 10.1093/rheumatology/ken485] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Manifestations of SSc in the gastrointestinal (GI) tract are common, occurring in 50-90% of patients. They typically result from the fibrosis that characterizes this disease. Manifestations of SSc can affect many sites within the GI tract, and patients may experience substantial dysfunction in the processes of motility, digestion, absorption and excretion. Oesophageal dysfunction is the most common GI manifestation, but patients may also experience dysfunction of the stomach, small intestine, colon and rectum, each of which can be responsible for severe and distressing symptoms. At present, few specific therapeutic options are available for the treatment of these patients, but relief of symptoms is often possible with appropriate knowledge and support. It is therefore particularly important to identify, monitor and manage these patients carefully, with a view to minimizing further degeneration and maximizing quality of life.
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Affiliation(s)
- A Forbes
- Department of Gastroenterology and Nutrition, University College Hospital, London, UK.
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59
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Kim JS, Lee KY. Endoscopic Hemoclipping Therapy for Gastric Angiodysplasia in a Child. Chonnam Med J 2009. [DOI: 10.4068/cmj.2009.45.2.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Joon Sung Kim
- Department of Pediatrics, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Kyung Yeon Lee
- Department of Pediatrics, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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60
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Cho S, Zanati S, Yong E, Cirocco M, Kandel G, Kortan P, May G, Marcon N. Endoscopic cryotherapy for the management of gastric antral vascular ectasia. Gastrointest Endosc 2008; 68:895-902. [PMID: 18640673 DOI: 10.1016/j.gie.2008.03.1109] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2007] [Accepted: 03/25/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) is an uncommon but clinically significant cause of chronic GI bleeding. OBJECTIVE To assess the efficacy and safety of cryotherapy for endoscopic treatment of GAVE. DESIGN Patients received 3 sessions of endoscopic cryotherapy at 3-week to 6-week intervals and had a follow-up endoscopy 4 weeks thereafter. They were followed prospectively in terms of clinical and endoscopic response. SETTING Tertiary-care center, between October 2004 and April 2006. PATIENTS The patients were 43 to 89 years of age, with a diagnosis of GAVE and documented iron deficiency anemia. Eight patients had a history of overt GI bleeding. Eight patients (67%) had previously been treated with argon plasma coagulation (APC) (median 6 sessions, range 1-10 sessions) and failed to respond or had a recurrence. RESULTS Twelve patients were enrolled. Six patients (50%) had a complete response, and 6 patients had a partial response. The mean number of units of blood transfused in the period of 3 months before cryotherapy and during the period of follow-up of 3 months was 4.6 and 1.7 units, respectively. An increased mean Hb level, from 9.9 to 11.3 g/dL, was noted. The average duration of the cryotherapy was 5 minutes (range 1-15 minutes). In 32 of 36 cryotherapy treatment sessions performed (89%), it was technically possible to treat more than 90% of GAVE lesions. There were no immediate cryotherapy-related complications, and none of the patients required admission after the procedure. LIMITATIONS A pilot study from a single center. CONCLUSIONS Endoscopic cryotherapy is a safe and effective treatment for GAVE. It appears to be effective, even for GAVE refractory to APC therapy. Optimal cryogen, delivery device, and treatment protocols are yet to be determined.
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Affiliation(s)
- Sarah Cho
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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61
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Marie I, Ducrotte P, Antonietti M, Herve S, Levesque H. Watermelon stomach in systemic sclerosis: its incidence and management. Aliment Pharmacol Ther 2008; 28:412-21. [PMID: 18498445 DOI: 10.1111/j.1365-2036.2008.03739.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND To date, there are no large endoscopic studies in systemic sclerosis (SSc), and both prevalence and characteristics of watermelon stomach in SSc have not been determined. AIMS To determine the prevalence, clinical presentation, endoscopic appearance, therapy success and long-term outcome in SSc patients with watermelon stomach and make predictions about which SSc patients are at risk for watermelon stomach. Patients and methods From 1990 to 2008, 264 patients were seen for evaluation of SSc. Data were collected as regards patients' characteristics, time of watermelon stomach onset, features, therapy and outcome of watermelon stomach. RESULTS Fifteen SSc patients (5.7%) exhibited watermelon stomach. SSc onset preceded watermelon stomach manifestations in 13 patients (86.7%). Most patients (86.7%) presented with iron-deficiency anaemia, two other patients experienced gastrointestinal haemorrhage. Gastroscopy disclosed typical 'watermelon stomach' characterized by prominent, erythematous stripes, radiating in a spoke-like fashion from the antrum to the pylorus. All patients received conservative therapy; because of deterioration of watermelon stomach, eight patients (53.3%) underwent endoscopic procedures. During follow-up, five patients (33.3%) exhibited recurrences of watermelon stomach. CONCLUSIONS Our series indicates that watermelon stomach should be considered when unexplained iron-deficiency anaemia occurs in SSc patients. Moreover, because watermelon stomach may be the first manifestation of SSc, patients with unexplained watermelon stomach should systematically undergo physical examination and autoantibody testing to detect the underlying SSc.
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Affiliation(s)
- I Marie
- Department of Internal Medicine, Rouen University Hospital, Rouen Cedex, France.
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62
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Wells CD, Harrison ME, Gurudu SR, Crowell MD, Byrne TJ, Depetris G, Sharma VK. Treatment of gastric antral vascular ectasia (watermelon stomach) with endoscopic band ligation. Gastrointest Endosc 2008; 68:231-6. [PMID: 18533150 DOI: 10.1016/j.gie.2008.02.021] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Accepted: 02/04/2008] [Indexed: 12/16/2022]
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) is characterized by mucosal and submucosal vascular ectasia causing recurrent GI hemorrhage. Treatment of GAVE with endoscopic thermal therapy (ETT) requires multiple sessions for destruction of vascular ectasia and control of bleeding. Endoscopic band ligation (EBL) has become the standard treatment of varices because it effectively obliterates the submucosal plexus of esophageal varices with an acceptably low rate of complications. Additionally, EBL has been used for control of bleeding from other GI vascular lesions. In patients with GAVE and recurrent GI hemorrhage, EBL may offer an alternative to ETT for treatment of large areas of diseased mucosa and submucosa. OBJECTIVE Our purpose was to compare EBL (n = 9) with ETT (n = 13) for the treatment of bleeding from GAVE. DESIGN Observational comparative study. PATIENTS Patients with gastric antral vascular ectasia with occult or overt bleeding. SETTING Mayo Clinic Arizona, a multispecialty academic medical center. INTERVENTION EBL or ETT with argon plasma coagulation or electrocautery. MAIN OUTCOME AND MEASUREMENTS Number of treatments to cessation of bleeding and posttreatment hemoglobin, hospitalization, and transfusion requirement. RESULTS There were no significant differences in the demographics, clinical presentation, associated portal hypertension, or mean hemoglobin values or the mean number of transfusions or hospitalizations between the 2 groups before treatment. Four patients in the EBL group had failed prior ETT. Compared with ETT, in exploratory statistical testing EBL had a significantly higher rate of bleeding cessation (67% vs 23%, P = .04), fewer treatment sessions required for cessation of bleeding (1.9 vs 4.7, P = .05), a greater increase in hemoglobin values (2.8 g/dL vs 0.9 g/dL, P = .05), a greater decrease in transfusion requirements (-12.7 vs -5.2, P = .02), and a greater decrease in hospital admissions (-2.6 vs -0.5, P = .02) during the follow-up period. Analysis of covariance showed significantly superior efficacy of EBL for cessation of bleeding, postprocedure transfusion, and hospitalization. One patient in the EBL group had postprocedure emesis and 1 in the ETT group had immediate post procedure bleeding. All patients in the EBL group had complete mucosal healing with minimal residual GAVE at follow-up endoscopy failed post-EBL. CONCLUSIONS Our initial experience suggests that EBL is superior to ETT for the management of GAVE. EBL required fewer treatment sessions for control of bleeding, had higher rates for cessation of bleeding, had a reduction in hospitalizations and transfusion requirements, and allowed for a significant increase in hemoglobin values.
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Affiliation(s)
- Christopher D Wells
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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63
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Domsic R, Fasanella K, Bielefeldt K. Gastrointestinal manifestations of systemic sclerosis. Dig Dis Sci 2008; 53:1163-74. [PMID: 17934861 DOI: 10.1007/s10620-007-0018-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 09/07/2007] [Indexed: 12/12/2022]
Abstract
Systemic sclerosis is a chronic disorder of connective tissue that affects the gastrointestinal tract in more than 80% of patients. Changes in neuromuscular function with progressive fibrosis of smooth muscle within the muscularis propria impair normal motor function, which may secondarily alter transit and nutrient absorption. Esophageal manifestations with gastroesophageal reflux and dysphagia are the most common visceral manifestation of the disease, often requiring more intense acid-suppressive medication. Gastric involvement may lead to gastroparesis, which can be found in up to 50% of patients. Severe small bowel disease can present as chronic intestinal pseudo-obstruction with distended loops of small intestine, bacterial overgrowth, impaired absorption and progressive development of nutritional deficiencies. While not studied as extensively, systemic sclerosis often also affects colorectal function resulting in constipation, diarrhea or fecal incontinence. Nutritional support and prokinetics have been used with some success to manage gastric and small or large bowel involvement in patients with systemic sclerosis. Despite advances in management, significant gastrointestinal manifestations of systemic sclerosis still carry a poor prognosis with a five-year mortality exceeding 50%.
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Affiliation(s)
- Robyn Domsic
- Division of Rheumatology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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64
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65
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Lecleire S, Ben-Soussan E, Antonietti M, Goria O, Riachi G, Lerebours E, Ducrotté P. Bleeding gastric vascular ectasia treated by argon plasma coagulation: a comparison between patients with and without cirrhosis. Gastrointest Endosc 2008; 67:219-25. [PMID: 18226684 DOI: 10.1016/j.gie.2007.10.016] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 10/02/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastric vascular ectasia (GVE) is an uncommon etiology of GI bleeding. GVE can affect not only patients with cirrhosis but also patients with a variety of chronic diseases. OBJECTIVE The aim of the study was to compare clinical and endoscopic patient characteristics and responses to treatment by argon plasma coagulation (APC) of bleeding GVE between patients with cirrhosis and noncirrhotic patients. DESIGN Retrospective study of consecutive patients. PATIENTS Between January 2001 and December 2005, 30 patients were treated by APC for bleeding GVE. INTERVENTIONS Clinical and endoscopic features and APC treatment success were compared between patients with cirrhosis (group 1) and noncirrhotic patients (group 2). MAIN OUTCOME MEASUREMENTS Endoscopic treatment efficacy was assessed on the recurrence of symptoms after APC. RESULTS Seventeen patients were cirrhotic and 13 had no cirrhosis. Cirrhotic patients presented more frequently with overt bleeding (65% vs 15%) and noncirrhotic patients with occult bleeding with iron deficiency anemia (35% vs 85%, P= .01). Endoscopy in noncirrhotic patients revealed more frequently a "watermelon" appearance (23.5% vs 76.9%, P= .008). Endoscopic treatment by APC was successful in 83.3% of patients (88.2% vs 76.9%, not significant). Patients from group 2 required significantly more APC sessions to achieve a complete treatment (2.18 vs 3.77, P= .04). CONCLUSIONS APC treatment of bleeding GVE was efficient and safe in cirrhotic and noncirrhotic patients in more than 80% of cases. Noncirrhotic patients required significantly more APC sessions to achieve a complete treatment. An endoscopic watermelon appearance and the use of antiplatelet drugs were associated with failure of APC.
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Affiliation(s)
- Stéphane Lecleire
- Department of Hepato-Gastroenterology and Nutrition, Endoscopy Unit, ADEN-EA3234/IFRMP23 Research Group, Rouen University Hospital Charles-Nicolle, Rouen, France
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Gross SA, Al-Haddad M, Gill KRS, Schore AN, Wallace MB. Endoscopic mucosal ablation for the treatment of gastric antral vascular ectasia with the HALO90 system: a pilot study. Gastrointest Endosc 2008; 67:324-7. [PMID: 18226696 DOI: 10.1016/j.gie.2007.09.020] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2007] [Accepted: 09/04/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) often results in GI bleeding and chronic anemia. Treatment options are limited and include medical, endoscopic, and surgical therapies. OBJECTIVE To assess the utility of endoscopic mucosal ablative therapy by using the HALO(90) system for patients with GAVE and recurrent bleeding. DESIGN Prospective open-label case series. SETTING Tertiary referral center. PATIENTS Six consecutive patients with GAVE, bleeding, and blood transfusion dependence. MAIN OUTCOME MEASUREMENTS Comparison of preablation and postablation Hb levels and transfusion requirements. To assess the number of ablation sessions needed to stabilize the Hb level and eliminate the need for blood transfusion. RESULTS Six patients, (4 men, mean age 58 years, range 47-65 years) underwent endoscopic mucosal ablation of antral lesions (mean procedure time 29 minutes; mean treatments 1.7, range 1-3). The mean Hb level improved from 8.6 to 10.2 g/dl (mean 2 months after the last ablation). Five of 6 patients are no longer dependent on blood transfusions to maintain a stable Hb level. LIMITATIONS This is a pilot study, with a small number of patients at a single center, with limited patient follow-up. CONCLUSIONS This study suggests that endoscopic mucosal ablation by using the HALO(90) system is a promising treatment option for chronic bleeding related to GAVE.
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Affiliation(s)
- Seth Andrew Gross
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida 32224, USA
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67
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Yew BS, Ng KY, Ang DSW, Mesenas SJ, Yap CK. Gastric Antral Vascular Ectasia Successfully Controlled by Argon Plasma Coagulation. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2007. [DOI: 10.47102/annals-acadmedsg.v36n8p702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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68
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Farooq FT, Wong RCK, Yang P, Post AB. Gastric outlet obstruction as a complication of argon plasma coagulation for watermelon stomach. Gastrointest Endosc 2007; 65:1090-2. [PMID: 17451706 DOI: 10.1016/j.gie.2006.10.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Accepted: 10/05/2006] [Indexed: 02/08/2023]
Affiliation(s)
- Farees T Farooq
- Division of Gastroenterology, Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio 44106-5066, USA
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69
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Shibukawa G, Irisawa A, Sakamoto N, Takagi T, Wakatsuki T, Imamura H, Takahashi Y, Sato A, Sato M, Hikichi T, Obara K, Ohira H. Gastric antral vascular ectasia (GAVE) associated with systemic sclerosis: relapse after endoscopic treatment by argon plasma coagulation. Intern Med 2007; 46:279-83. [PMID: 17379994 DOI: 10.2169/internalmedicine.46.6203] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
In this report, we present a case of gastric antral vascular ectasia (GAVE) associated with systemic sclerosis and interstitial pneumonitis. This case showed resistance to endoscopic treatment using argon plasma coagulation (APC). After initial recognition of GAVE as the origin of persistent anemia, three sessions of APC were performed and dilated vessels on the antrum were eliminated completely. Five months after primary treatment, follow-up endoscopy revealed deformity of the gastric antrum caused by ulcer scars induced by APC, with no vascular ectasia. Ten months later, the patient showed anemia and recurrence of GAVE on endoscopy. Ablation using APC was performed again, thereby eradicating recurrent GAVE completely. At a two months' follow-up, however, recurrent GAVE was indicated. In spite of GAVE eradication by APC, a third recurrence of GAVE was observed after 32 months. During the follow-up period, systemic sclerosis and interstitial pneumonitis were controlled clinically by administration of methyl prednisolone with no aggravation.
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Affiliation(s)
- Goro Shibukawa
- Department of Internal Medicine 2, Fukushima Medical University School of Medicine, Fukushima
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70
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Sabljak P, Velicković D, Stojakov D, Bjelović M, Ebrahimi K, Spica B, Sljukić V, Pesko P. [Less frequent causes of upper gastrointestinal bleeding]. ACTA CHIRURGICA IUGOSLAVICA 2007; 54:119-23. [PMID: 17633871 DOI: 10.2298/aci0701119s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Upper gastrointestinal (GI) bleeding represents emergency which despites modern advances in treatment still carry substantial mortality. Mortality remained relatively constant in the last 50 years at approximately 12%. Peptic ulcers remain the most common cause of upper GI bleeding and account approximately 50% of all cases. Next leading causes are esophageal and gastric varices, and gastroduodenal erosions. Mallory Weiss tears, angiodysplasia and gastric antral vascular ectasia (GAVE)-Watermelon stomach are less frequent but important causes of upper GI bleeding that contribute substantially to the overall morbidity and mortality. Recognition of such lesions is crucial to provide effective hemostasis. In most cases endoscopic therapy is procedure of choice which significantly improved the outcome of patients. In cases where endoscopic hemostasis is not effective, or patients rebleed after initial control surgical therapy may be required. This article will review recent advances in diagnosis and therapy of upper GI bleeding caused by Mallory Weiss tears, angiodysplasia or Watermelon stomach.
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Affiliation(s)
- P Sabljak
- Centar za hirurgiju jednjaka, I Hirurska klinika, Institut za bolesti digestivnog sistema, KCS, Beograd
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71
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Sinha SK, Udawat HP, Varma S, Lal A, Rana SS, Bhasin DK. Watermelon stomach treated with endoscopic band ligation. Gastrointest Endosc 2006; 64:1028-31. [PMID: 17140926 DOI: 10.1016/j.gie.2006.05.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2006] [Accepted: 05/09/2006] [Indexed: 12/13/2022]
Affiliation(s)
- Saroj K Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research Chandigarh, India
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72
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Polese L, Angriman I, Pagano D, Tenderini ML, Polese F, Frego M, D'Amico DF, Norberto L. Laser therapy and surgical treatment in transfusion-dependent patients with upper-gastrointestinal vascular ectasia. Lasers Med Sci 2006; 21:140-6. [PMID: 16897110 DOI: 10.1007/s10103-006-0389-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2006] [Revised: 05/09/2006] [Accepted: 06/09/2006] [Indexed: 12/11/2022]
Abstract
We report the results of endoscopic laser therapy on 59 patients with upper gastrointestinal vascular ectasia. After 300 sessions, complications were two nonbleeding and three bleeding ulcers, treated successfully with endoscopic therapy. After treatment, blood transfusions were abolished in 61% and reduced in 22% of the patients, whereas 17% of the patients were nonresponders and 5% died for bleeding. Treatment outcome correlated with endoscopic healing, number of yearly transfusions, and lesions' localization. Patients, who did not respond to laser therapy by the sixth session, showed no improvement afterwards. Four patients with persistence of bleeding despite laser therapy underwent surgery and in three of them, a long-term control of bleeding was obtained. In conclusion, laser therapy was safe and effective; nonetheless, surgical treatment should be considered, after adequate staging, for those patients receiving more than 10 blood units per year or who have undergone more than six laser sessions without improvement.
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Affiliation(s)
- Lino Polese
- Department of Surgical and Gastroenterological Sciences, First Surgical Clinic, University of Padova, Padova, Italy
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73
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Szilagyi A, Ghali MP. Pharmacological therapy of vascular malformations of the gastrointestinal tract. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2006; 20:171-8. [PMID: 16550261 PMCID: PMC2582970 DOI: 10.1155/2006/859435] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Vascular malformation (AVM) in the gastrointestinal tract is an uncommon, but not rare, cause of bleeding and iron deficiency anemia, especially in an aging population. While endoscopic coagulative therapy is the method of choice for controlling bleeding, a substantial number of cases require additional therapy. Adjunctive or even primary phamacotherapy may be indicated in recurrent bleeding. However, there is little evidence-based proof of efficacy for any agent. The bulk of support is derived from anecdotal reports or case series. The present review compares the outcome of AVM after no intervention, coagulative therapy or focus on pharmacological agents. Most of the literature encompasses two common AVMs, angiodysplasia and hereditary hemorrhagic telangiectasia. Similarly, the bulk of information evaluates two therapies, hormones (estrogen and progesterone) and the somatostatin analogue octreotide. Of these, the former is the only therapy evaluated in randomized trials, and the results are conflicting without clear guidelines. The latter therapy has been reported only as case reports and case series without prospective trials. In addition, other anecdotally used medications are discussed.
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Affiliation(s)
- Andrew Szilagyi
- Division of Gastroenterology, Department of Medicine, Sir Mortimer B Davis Jewish General Hospital, McGill University School of Medicine, Montreal, Quebec.
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74
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Abstract
Watermelon stomach (WMS), or gastric antral vascular ectasia, is an uncommon but clinically important cause of chronic occult or overt gastrointestinal (GI) blood loss. Patients typically present with symptomatic anemia and hemoccult positive stools. Although the diagnosis is based primarily on the typical endoscopic appearance, the lesion may be overlooked on initial evaluation or interpreted as "gastritis." Gastric biopsy may be helpful in confirming the diagnosis by showing vascular ectasia, typically without inflammation. WMS is idiopathic but is often associated with autoimmune diseases or cirrhosis of the liver. The majority of patients with classic WMS are elderly and female. In contrast, there is no gender predominance with the diffuse pattern associated with cirrhosis. General supportive care includes transfusion of blood products as necessary to control symptomatic anemia and coagulopathy, iron replacement therapy by oral or parenteral routes, identification and treatment of iatrogenic (eg, warfarin) or hereditary (eg, von Willebrand's disease) coagulopathy, and avoidance of substances that might cause gastric mucosal damage and/or bleeding (eg, aspirin, NSAIDs, alcohol). The goals of therapy are to eliminate or decrease the need for blood transfusions, hospitalization, office visits, and endoscopic therapy sessions aimed at cessation of GI blood loss and resolution of symptomatic anemia. Multipolar electrocoagulation is our preferred technique for endoscopic ablation of WMS. A 10-Fr probe (3.2 mm in diameter) is used at a generator setting of 12 to 16 W. Pulse duration can be as short as 1 to 2 seconds if a pinpoint coagulation technique is used, or continuous if a paint-stroke technique is used to coagulate all vascular stripes in the classic WMS pattern or as many small lesions as possible in the diffuse type. Other techniques we currently use are argon plasma coagulation (APC) or heater probe. In the past, lasers (neodymium: yttrium-aluminum-garnet , KTP, or argon) were successfully used for such treatments. An initial treatment interval of 4 to 8 weeks should allow for interim healing of iatrogenic ulcers. Patients are routinely given standard doses of available proton-pump inhibitors (PPIs) to facilitate healing of iatrogenic ulcers and to prevent secondary bleeding. The treatment interval can be gradually lengthened as the long-term goals of obliteration of angiomata and resolution of anemia are reached. Side effects may include iatrogenic ulceration at the site of treatment, bleeding, and transient abdominal pain. Antral scarring (after APC or Nd:YAG laser) and hyperplastic polyps have also been reported after endoscopic treatment of classic WMS. Surgical antrectomy is very effective in the prevention of bleeding but has substantial (5% to 10%) mortality in older patients with comorbidity and is now reserved for endoscopic failures.
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Affiliation(s)
- Gareth S Dulai
- Center for Outcomes Research and Education, CURE DDRC, David Geffen School of Medicine, UCLA, Southern California Permanente Medical Group, Bellflower, CA 90706, USA.
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75
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Esrailian E, Gralnek IM. Nonvariceal upper gastrointestinal bleeding: epidemiology and diagnosis. Gastroenterol Clin North Am 2005; 34:589-605. [PMID: 16303572 DOI: 10.1016/j.gtc.2005.08.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Nonvariceal upper gastrointestinal bleeding remains an important cause of patient morbidity, mortality, and use of considerable health care resources. An early and accurate diagnosis is critical for guiding appropriate management and facilitating patient care. This article reviews the most recent epidemiologic data on acute nonvariceal upper gastrointestinal bleeding and outlines important aspects of making the diagnosis.
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Affiliation(s)
- Eric Esrailian
- David Geffen School of Medicine at UCLA, VA Greater Los Angeles Healthcare System, UCLA/VA Center for Outcomes Research and Education, CA 90073, USA
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76
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Kuroiwa Y, Suzuki N, Mizue N, Hori T, Endo T, Yoshida Y, Tsutsumi H. Gastric antral vascular ectasia in 2-yr-old girl undergoing unrelated cord blood stem cell transplantation. Pediatr Transplant 2005; 9:788-91. [PMID: 16269052 DOI: 10.1111/j.1399-3046.2005.00364.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Gastrointestinal bleeding is a common complication after hematopoietic stem cell transplantation (HSCT) and is often related to acute graft-vs.-host disease (aGVHD). Gastric antral vascular ectasia (GAVE), recently recognized as a complication after HSCT, is a rare cause of severe gastrointestinal bleeding, which has only been reported in adult patients so far. We report a 2-yr-old girl who developed GAVE after unrelated cord blood stem cell transplantation (CBSCT) as treatment of intractable Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis (EBV-HLH). Her conditioning regimen for CBSCT consisted of etoposide, busulfan, and cyclophosphamide. She was doing well after CBSCT without recurrence and developed only grade I aGVHD. She suddenly developed coffee ground emesis, tarry stools and severe anemia 76 days after CBSCT. As antacids were ineffective, esophagogastroduodenoscopy was performed and revealed GAVE on day 97. Endoscopic coagulation therapy was performed twice; subsequently, she needed no further transfusions and there was no clinical recurrence of GAVE.
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Affiliation(s)
- Yuki Kuroiwa
- Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan.
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77
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Scialla TJ, Cavanaugh KL. The rare needle in a diagnostic haystack. Am J Med 2005; 118:720-2. [PMID: 15989904 DOI: 10.1016/j.amjmed.2005.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2004] [Indexed: 10/25/2022]
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78
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Kovacs TO. Mallory–Weiss Tears, Angiodysplasia, Watermelon Stomach, and Dieulafoy’s: A Potpourri. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2005. [DOI: 10.1016/j.tgie.2005.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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79
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Affiliation(s)
- Shawn C Chen
- Department of Medicine, Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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80
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Laser literature watch. JOURNAL OF CLINICAL LASER MEDICINE & SURGERY 2004; 22:69-75. [PMID: 15117491 DOI: 10.1089/104454704773661010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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