Two cases of gastric antral vascular ectasia--response to medical treatment

Pharmacotherapy for the Treatment of Gastric Antral Vascular Ectasia: A Narrative Review

Gastric antral vascular ectasia (GAVE) is an uncommon clinical entity leading to recurrent gastrointestinal bleeding. There is no consensus regarding treatment of GAVE. Endoscopic therapy is the preferred treatment option, but has a fairly high recurrence rate. Surgical resection can completely resolve GAVE, but is invasive with a relatively high risk of postoperative complications. Recently, the role of pharmacotherapy for GAVE has been recognized. However, the evidence is limited to scattered case reports or small case series. This review comprehensively summarizes the efficacy and side effects of drugs commonly used for the treatment of GAVE, including octreotide, cyproheptadine, cyclophosphamide, prednisolone, estrogen-progesterone, thalidomide, bevacizumab, and tranexamic acid.

Radiofrequency ablation using Barrx® for the endoscopic treatment of gastric antral vascular ectasia: a series of three cases and a review of the literature on treatment options

Gastric antral vascular ectasia (GAVE), also known as "watermelon stomach", is an uncommon condition, which can cause gastrointestinal bleeding due to rupture of blood vessels that line the stomach. The pathogenesis of GAVE remains unclear; however it is thought that hemodynamic changes, mechanical stress, and autoimmune factors all have a part to play. A range of conditions are also commonly associated with the syndrome, such as portal hypertensive gastropathy, liver cirrhosis, and autoimmune disorders. Less commonly, chronic renal failure, cardiac diseases, and bone marrow transplantation have coexisted with GAVE. The diagnosis is usually based on visualization of the tissue upon endoscopy; however, histology plays a role in uncertain cases. The typical "watermelon" appearance relates to the tissue having a striped appearance radiating out from the pylorus. Medical treatment has failed to show satisfactory results and surgery is usually considered as a last resort, due to its increased risk for complications and mortality. Lasers and argon plasma coagulation have been used recently, and been shown to be as effective as surgery and a safer option. We present three cases of gastric antral vascular ectasia treated at our institution with radiofrequency ablation and review the literature on treatment modalities for GAVE.

Portal hypertensive gastropathy and gastric antral vascular ectasia

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.

Radiofrequency ablation for refractory gastric antral vascular ectasia (with video)

BACKGROUND

Gastric antral vascular ectasia (GAVE) is a cause of upper GI bleeding and chronic anemia. Although upper endoscopy with argon plasma coagulation (APC) is an accepted therapy for GAVE, many patients continue to bleed and remain transfusion dependent after therapy. Radiofrequency ablation (RFA) may provide an alternative therapeutic option for GAVE.

OBJECTIVE

To determine the efficacy and safety of RFA for patients with GAVE who remain transfusion dependent after APC treatment.

DESIGN

Open-label prospective cohort study of patients with GAVE refractory to APC.

SETTING

Academic tertiary referral center.

PATIENTS

GAVE patients with previous failed APC therapy, chronic anemia, and transfusion dependence.

INTERVENTIONS

Endoscopic RFA to the gastric antrum using the HALO(90) ULTRA ablation catheter until transfusion independence is achieved or a maximum of 4 sessions are performed.

MAIN OUTCOME MEASUREMENTS

Transfusion requirements before and after RFA. Secondary outcomes are hemoglobin before and 6 months after RFA completion, number of RFA sessions, and complications.

RESULTS

Twenty-one patients underwent at least 1 RFA session with ablation of GAVE lesions. At 6 months after completion of the course of RFA therapy, 18 of 21 patients (86%) were transfusion independent. Mean hemoglobin increased from 7.8 to 10.2 in responders (n = 18). Two adverse events occurred (minor acute bleeding and superficial ulceration); both resolved without intervention.

LIMITATIONS

Single-center, single-operator, and nonrandomized design.

CONCLUSIONS

RFA is safe and effective for treating patients with refractory GAVE after attempted APC.

Laser therapy and surgical treatment in transfusion-dependent patients with upper-gastrointestinal vascular ectasia

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.

Review article: current therapeutic options for gastric antral vascular ectasia

Gastric antral vascular ectasia, or 'watermelon stomach', is a rare but important cause of gastrointestinal blood loss and anaemia, which has characteristic endoscopic and histological features. The pathogenesis of this condition remains unclear; however, many associated disorders have been documented. Various medical, surgical and endoscopic therapeutic modalities have been attempted with variable success. Leading contenders for the therapeutic modality of choice include hormonal therapy, endoscopic Nd:YAG laser and argon plasma coagulation. Randomized controlled trials to identify the ideal treatment method are lacking at present.

Gastric antral vascular ectasia causing severe anemia

Gastric antral vascular ectasia (GAVE) that caused continuous gastrointestinal bleeding is reported in a 76-year-old woman who had been treated with repeated blood transfusions because of severe anemia. Endoscopic examination was performed and diffuse speckled telangiectasia of the entire antrum was observed. Laboratory data showed SGOT > SGPT, decreased chE level and the increased levels of serum gastrin and ICG at 15 min. Anti-HCV antibody was positive. Image examination revealed splenomegaly. There was no family history of telangiectasia, and no telangiectasia was found in other organs. The diagnosis was established as GAVE with liver cirrhosis. Surgical resection of the distal stomach resulted in termination of the bleeding, and the cirrhotic changes of the surface of the liver were revealed at that time, providing further evidence of liver cirrhosis. Although the pathogenesis of GAVE is unknown, liver cirrhosis and hypergastrinemia are thought to be associated with the condition. Importantly, this condition is a cause of severe gastrointestinal bleeding in elderly patients.

Bleeding from gastric antral vascular ectasia in marrow transplant patients

BACKGROUND

Gastric antral vascular ectasia (GAVE) leads to blood loss in the disorders of "watermelon stomach" and portal gastropathy, but is not a commonly recognized complication of marrow transplantation.

METHODS

GAVE was diagnosed when capillary ectasia, focal capillary thromboses, and fibromuscular hyperplasia were identified in antral mucosal biopsy specimens. Marrow transplant patients bleeding from GAVE were reviewed to ascertain common variables in their pretransplant, posttransplant, and bleeding course.

RESULTS

Six patients developed bleeding due to GAVE. The onset of bleeding was 18 to 94 days after transplant and required an average of 37 U of blood (range, 2 to 130 U). Two patients stopped bleeding after restoration of platelet counts. Two patients had surgical antral resections; both died of multiorgan failure after surgery. Two patients had successful endoscopic laser ablation of vascular lesions and survived. Factors possibly associated with GAVE included male gender, VOD of the liver, oral busulfan as part of the conditioning regimen, and growth factor use after transplant.

CONCLUSIONS

GAVE was a cause of gastric bleeding in six patients with marrow transplant patients. Restoration of platelet counts and endoscopic laser photocoagulation are the therapies of choice for ongoing bleeding in these patients.

Management of upper gastrointestinal bleeding in the patient with chronic liver disease

This article reviews the management of severe upper gastrointestinal bleeding in the patient with chronic liver diseases. The initial assessment, diagnostic work-up, and treatment options for variceal and nonvariceal bleeding are discussed. The role of diagnostic and therapeutic endoscopy for esophagogastric varices is reviewed with special emphasis on new endoscopic techniques including variceal band ligation and cyanoacrylate injection. Various pharmacologic, surgical, and radiologic treatment options for variceal bleeding also are discussed. In addition, nonvariceal causes of severe upper gastrointestinal bleeding are reviewed including peptic ulcer diseases, Mallory-Weiss tear, portal hypertensive gastropathy, and gastric antral vascular ectasia.

A case of gastric antral vascular ectasia--increase of neuroendocrine cells in the antrum

We report an 82-year-old woman with severe iron deficiency anemia who was found to have gastric antral vascular ectasia (GAVE). As she required repeated blood transfusion for the anemia and did not respond to various medical treatments, she was referred for antrectomy. The pathogenesis of GAVE is still obscure and may involve many factors. In our patient, immunohistochemical studies of the resected stomach disclosed a marked increase of neuroendocrine cells. The majority of these hyperplastic neuroendocrine cells, furthermore, showed immunoreactivity for 5-hydroxytryptamine (serotonin). These findings suggest that neuroendocrine mediators, serotonin in particular, may have been responsible for the local vasodilation.