Treatment of gastropathy and gastric antral vascular ectasia in patients with portal hypertension

A case report of gastric antral vascular ectasia treated by endoscopic band ligation combined with lauromacrogol injection

RATIONALE

Gastric antral vascular ectasia (GAVE) is a rare acquired lesion characterized by vascular dilation in the gastric antrum, frequently results in occult or overt gastrointestinal bleeding. Endoscopic intervention remains the cornerstone of therapy. Argon plasma coagulation was previously considered a first treatment option. But recently, endoscopic band ligation (EBL) has emerged as an alternative, increasingly favored for its safety and efficacy. Nonetheless, a consensus on the most effective treatment approach has yet to be established.

PATIENT CONCERNS

A 74-year-old female was hospitalized for persistent chest tightness and dyspnea for 1 year. Physical examination showed an anemic appearance with normal blood pressure. Upon admission to the hospital, the blood routine examination revealed severe anemia and the fecal occult blood test was persistently positive.

DIAGNOSES

The endoscopic observations and histological evidence led to a diagnosis of GAVE for the patient.

INTERVENTIONS

Considering the poor response to prior pharmacotherapy, endoscopic intervention was selected for this hospitalization. The initial EBL alone did not yield particularly satisfactory results. Combining EBL with lauromacrogol injection as a subsequent treatment resulted in encouraging outcomes.

OUTCOMES

At the 6-week follow-up, the patient exhibited a negative fecal occult blood test, normalization of hemoglobin level, and endoscopic images demonstrated near complete resolution of vascular ectasias.

LESSONS

The combination of EBL with lauromacrogol injection has shown a satisfactory short-term outcome, providing a new option for the endoscopic management of GAVE. However, its long-term efficacy still requires further observation.

Treatment of Acute Variceal Bleeding in 2021-When to Use Transjugular Intrahepatic Portosystemic Shunts?

Variceal bleeding in patients with cirrhosis is associated with high mortality if not adequately managed. Treatment of acute variceal bleeding with adequate resuscitation maneuvers, restrictive transfusion policy, antibiotic prophylaxis, pharmacologic therapy, and endoscopic therapy is highly effective at controlling bleeding and preventing death. There is a subgroup of high-risk cirrhotic patients in whom this strategy fails, however, and who have a high-mortality rate. Placing a preemptive transjugular intrahepatic portosystemic shunt in these high-risk patients, as soon as possible after admission, to achieve early control of bleeding has proved not only to control bleeding but also to improve survival.

Irsogladine maleate alters expression of a tight junction protein in portal hypertensive gastropathy

BACKGROUND AND AIM

Portal hypertensive gastropathy (PHG) is characterized by noninflammatory edema and vasodilatation of the lamina propria of the mucosal epithelium. In addition, the alterations of intercellular junction proteins and dilatation of the endothelial gaps have been reported. In this study, we examined whether irsogladine maleate (IM), a gastric mucosal protective agent, has the potential to improve PHG by restoration of tight junctions (TJs).

METHODS

Twenty-four patients with PHG were registered and randomly assigned into two groups: 12 patients in the IM-administration group and 12 patients in the non-administration group. In the administration group, IM (4 mg/day) was administered orally for 12 weeks. Gastric mucosa with a red color in patients with PHG were obtained endoscopically on the registration day and 12 weeks later. The endoscopic findings were evaluated, an immunohistochemical analysis of claudin-3 (a TJ protein) expression in gastric mucosal tissues by a laser microscope was performed, and claudin-3 expression was quantified by western blot analysis.

RESULTS

Irsogladine maleate improved the degree of PHG in 2/12 patients endoscopically, in contrast to none of the 12 patients in the non-administration group. Immunohistochemical analysis showed that expression of claudin-3 increased in 8/12 patients in the IM-administration group and 2/12 patients in the non-administration group (P = 0.036). Western blot analysis revealed that the increase in claudin-3 after 12 weeks was significantly higher in the IM-administration group than in the non-administration group (P = 0.010).

CONCLUSIONS

The present pilot study suggested that IM might improve the gastric mucosa in PHG through restoration of TJ-protein claudin-3.

Gastric Antral Vascular Ectasia Pathogenesis and the Link to the Metabolic Syndrome

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.

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.

Portal hypertensive gastropathy: a review

Portal hypertensive gastropathy (PHG) occurs as a complication of cirrhotic or non-cirrhotic portal hypertension. Although the pathogenesis of PHG is not completely understood, evidence suggests that the key factor for the development of PHG is portal hypertension. PHG is clinically important because it may cause acute (and even) massive or insidious, blood loss. The diagnosis of PHG is (only) made endoscopically; it is most often characterized by an abnormality of the gastric mucosa described as a mosaic-like pattern resembling 'snake-skin', with or without red spots and the endoscopic pattern is key its diagnosis. Unfortunately, standardization of the endoscopic diagnostic criteria for PHG is poor and consensus is generally lacking, resulting in a wide range of reported prevalence. Pharmacological therapies, presumably reducing portal pressure and gastric blood flow, have been used to treat acute bleeding; propanolol, a non-selective beta-blocker (24-480 mg/day), has been used most frequently. Endoscopic treatment for PHG bleeding plays a small, if any, role in the treatment of PHG. TIPS and shunt surgery have not been extensively analysed as a treatment for acute or chronic PHG bleeding, but they appear to lessen the severity of PHG. Secondary prophylaxis of PHG bleeding with non-selective beta-blockers is recommended. There is not enough evidence to support the use of beta-blockers in primary prophylaxis of PHG bleeding, even in cases of severe PHG (however, non-selective beta-blockers are recommended if varices are present). Further studies are needed to clarify the role of PHG in suspected chronic gastrointestinal bleeding.