Long-term follow-up in patients with gastric antral vascular ectasia (GAVE) after treatment with endoscopic band ligation (EBL)

A delayed gastric antral vascular ectasia: A case report and literature review

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.

Role of Endoscopy in the Diagnosis, Grading, and Treatment of Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are 2 distinct gastric vascular abnormalities that may present with acute or chronic blood loss. PHG requires the presence of portal hypertension and is typically associated with chronic liver disease, whereas there is controversy about the association of GAVE with chronic liver disease and/or portal hypertension. Distinguishing between GAVE and PHG is crucial because their treatment strategies differ. This review highlights characteristic endoscopic appearances and the clinical features of PHG and GAVE, which, in turn, aid in their appropriate management.

Upper gastrointestinal bleeding from gastric antral vascular ectasia following cocaine use: case presentation and review of literature

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.

Gastric Antral Vascular Ectasia (GAVE) a case report, review of the literature and update of techniques

Introduction and importance

Gastric Antral Vascular Ectasia is a rare disorder that causes up to 4 % of severe acute gastrointestinal bleeding. It affects elderly females with iron deficiency anemia due to chronic blood loss as a common presenting sign.

Case presentation

We report the case of a 70-year-old man admitted to the Urgency Department for severe asthenia associated with abdominal pain and severe anemia. An urgent upper endoscopic examination showed antral hyperemic streaks and vascular ectasias extending from the pyloric ring to the gastric body as well as signs of recent bleeding. Histological results demonstrated the pathognomonic features of GAVE.

Clinical discussion

The first line treatment is considered argon plasma coagulation (APC), given its wider availability, safety, efficacy and cost-effectiveness. In current literature, other therapies and different types of endoscopic treatments have been proposed, such as EBL, RFA and Yag: laser. To date, there is no specific recommendation that privileges one method over another in the treatment of GAVE, although APC has proven effective and even better in terms of complications and costs than the other techniques.

Conclusion

In our experience, endoscopic coagulation with APC probes is a relatively easy-to-use technique with low cost, minimal invasiveness and provides immediate results.

On the other hand, a standardized algorithm is also required concerning to the different subtypes to give the best treatment in every case.

Comparison of portal hypertensive gastropathy and gastric antral vascular ectasia: an update

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.

Endoscopic band ligation in the treatment of gastric antral vascular ectasia: a systematic review and meta-analysis

BACKGROUND AND AIMS

Gastric antral vascular ectasia (GAVE) is typically treated by endoscopic thermal therapies. Endoscopic band ligation (EBL) has been reported in the treatment of GAVE with encouraging results. However, EBL is not widely used to this end.

METHODS

We conducted a comprehensive search of several databases (inception to May 2021) to identify studies reporting on the use of EBL in the treatment of GAVE. A random-effects model was used to calculate the pooled rates; I2 values and 95% prediction intervals were calculated to assess the heterogeneity.

RESULTS

Ten studies (194 patients) were included in the final analysis. The pooled rate of treatment responders with EBL in GAVE was 81% (95% confidence interval [CI], 62.2-91.7), and GAVE recurrence was 15.4% (95% CI, 4.5-41.3). The pooled mean number of treatment sessions required was 2.4 (95% CI, 2.2-2.7), and the number of bands used to achieve eradication per patient was 15.1 (95% CI, 10.7-19.4). The pooled mean difference of pre- to post-treatment hemoglobin was 1.5 (95% CI, .9-2.2; P = .001), pre- to post-treatment units of packed red blood cells transfused was 1.1 (95% CI, .4-1.9; P = .002), and pre- to post-treatment hospital length of stay was .5 days (95% CI, .1-.9; P = .01). The pooled rate of overall adverse events was 15.9% (95% CI, 10.4-23.7).

CONCLUSIONS

EBL demonstrated excellent clinical outcomes in the treatment of GAVE with minimal adverse events. Multicenter randomized controlled trials comparing EBL and other modalities as initial therapy are warranted.

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.

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

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.

Endoscopic treatment for gastric antral vascular ectasia

Gastric antral vascular ectasia (GAVE) is one of the uncommon causes of upper gastrointestinal bleeding. Major treatment of GAVE includes pharmacotherapy, endoscopy, and surgery. The efficacy and safety of pharmacotherapy have not been sufficiently confirmed; and surgery is just considered when conservative treatment is ineffective. By comparison, endoscopy is a common treatment option for GAVE. This paper reviews the currently used endoscopic approaches for GAVE, mainly including argon plasma coagulation (APC), radiofrequency ablation (RFA), and endoscopic band ligation (EBL). It also summarizes their efficacy and procedure-related adverse events. The endoscopic success rate of APC is 40-100%; however, APC needs several treatment sessions, with a high recurrence rate of 10-78.9%. The endoscopic success rates of RFA and EBL are 90-100% and 77.8-100%, respectively; and their recurrence rates are 21.4-33.3% and 8.3-48.1%, respectively. Hyperplastic gastric polyps and sepsis are major adverse events of APC and RFA; and Mallory-Weiss syndrome is occasionally observed after APC. Adverse events of EBL are rare and mild, such as nausea, vomiting, esophageal or abdominal pain, and hyperplastic polyps. APC is often considered as the first-line choice of endoscopic treatment for GAVE. RFA and EBL have been increasingly used as alternatives in patients with refractory GAVE. A high recurrence of GAVE after endoscopic treatment should be fully recognized and cautiously managed by follow-up endoscopy. In future, a head-to-head comparison of different endoscopic approaches for GAVE is warranted.

Endoscopic band ligation in the treatment of gastric antral vascular ectasia: a systematic review and meta-analysis

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.

Clinical usefulness of combination therapy with polidocanol injection and argon plasma coagulation for gastric antral vascular ectasia

Background and Aim

Gastric antral vascular ectasia (GAVE) causes gastrointestinal bleeding. The initial treatment for GAVE bleeding is endoscopic hemostasis, and currently, the most performed technique to achieve hemostasis is argon plasma coagulation (APC). However, APC is associated with a high recurrence rate. To overcome this limitation, we examined the outcomes of the combination therapy of APC and polidocanol injection (PDI) for treating GAVE.

Methods

We retrospectively analyzed the outcomes of 15 consecutive GAVE patients treated with PDI + APC at Hiroshima University Hospital between November 2011 and September 2019 with respect to clinical characteristics, hemostatic efficacy, complications related to treatment, and recurrence rate.

Results

The mean age of patients (4 men and 11 women) was 74 ± 8.4 years. Patients had comorbidities of liver cirrhosis (seven patients, 47%), chronic renal failure (seven patients, 47%), and autoimmune diseases (seven patients, 47%). Endoscopic hemostasis with PDI + APC was performed in all patients (n = 15). The mean number of PDIs attempted to stop bleeding was 1.5 ± 0.8 (1–4), and the mean number of APCs attempted was 2.1 ± 1.2 (1–5). Complications related to treatment occurred in two patients (14%): ulceration in one patient and hematoma in another patient, both of whom were treated conservatively. Two patients (13%) had recurrences during the follow‐up period (average period, 42 months). Both were cured with additional treatment of PDI only.

Conclusion

The combination therapy of PDI and APC is effective for GAVE with a low recurrence rate.

Endoscopic band ligation compared to thermal therapy for gastric antral vascular ectasia: A systematic review and meta-analysis

Background

Gastric antral vascular ectasia is an infrequent cause of gastrointestinal‐related blood loss manifesting as iron‐deficiency anemia or overt gastrointestinal bleeding, and is associated with increased healthcare burdens. Endoscopic therapy of gastric antral vascular ectasia most commonly involves endoscopic thermal therapy. Endoscopic band ligation has been studied as an alternative therapy with promising results in gastric antral vascular ectasia.

Aims

The primary aim was to compare the efficacy of endoscopic band ligation and endoscopic thermal therapy by argon plasma coagulation for the management of bleeding gastric antral vascular ectasia in terms of the mean post‐procedural transfusion requirements and the mean hemoglobin level change. Secondary outcomes included a comparison of the number of sessions needed for cessation of bleeding, the change in transfusion requirements, and the adverse events rate.

Methods

PubMed, Medline, SCOPUS, Google Scholar, and the Cochrane Controlled Trials Register were reviewed. Randomized controlled clinical trials and retrospective studies comparing endoscopic band ligation and endoscopic thermal therapy in bleeding gastric antral vascular ectasia, with a follow‐up period of at least 6 months, were included. Statistical analysis was done using Review Manager.

Results

Our search yielded 516 papers. After removing duplicates and studies not fitting the criteria of selection, five studies including 207 patients were selected for analysis. Over a follow‐up period of at least 6 months, patients treated with endoscopic band ligation had significantly lower post‐procedural transfusion requirements (MD −2.10; 95% confidence interval (−2.42 to −1.77)) and a significantly higher change in the mean hemoglobin with endoscopic band ligation versus endoscopic thermal therapy (MD 0.92; 95% confidence interval [0.39–1.45]). Endoscopic band ligation led to a fewer number of required sessions (MD −1.15; 95% confidence interval [−2.30 to −0.01]) and a more pronounced change in transfusion requirements (MD −3.26; 95% confidence interval [−4.84 to −1.68]). There was no difference in adverse events.

Conclusion

Results should be interpreted cautiously due to the limited literature concerning the management of gastric antral vascular ectasia. Compared to endoscopic thermal therapy, endoscopic band ligation for the management of bleeding gastric antral vascular ectasia led to significantly lower transfusion requirements, showed a trend toward more remarkable post‐procedural hemoglobin elevation, and a fewer number of procedures. Endoscopic band ligation may improve outcomes and lead to decreased healthcare burden and costs.

Is Endoscopic Band Ligation a Superior Treatment Modality for Gastric Antral Vascular Ectasia Compared to Argon Plasma Coagulation?

BACKGROUND/AIMS

Gastric antral vascular ectasia (GAVE) is a rare acquired vascular lesion of the gastric antrum. The most frequent presentation of GAVE is iron deficiency anemia. Endoscopic therapy is the mainstay of treatment. However, there is no consensus regarding the optimal treatment modality.

METHODS

A retrospective cohort study was performed on patients with GAVE, including patients receiving endoscopic therapy. Treatment was with either argon plasma coagulation (APC) or endoscopic band ligation (EBL). Basic demographic data, indication for index procedure, number of sessions, and pre- and post-hemoglobin levels were collected. The aim of the study was to compare outcomes across the two treatment modalities.

RESULTS

One hundred and seventeen diagnoses of GAVE were made. Sixty-two patients (53%) required endoscopic treatment for symptomatic GAVE (female, n=38, 61%; mean age of 74.4 years). Two hundred and eighteen procedures were performed during the study period. APC was performed (n=161, 74%) more frequently than EBL (n=57, 26%). Patients treated with APC at index required a median 5 subsequent therapeutic interventions (APC or EBL), while those treated with EBL at index required a further 2.9 treatments (EBL only) (p<0.05).

CONCLUSION

APC was the most common treatment modality employed. We demonstrate an increasing incidence of EBL. Patients treated with EBL at index treatment required fewer subsequent treatment sessions and had a greater mean rise in hemoglobin. This suggests a more effective endoscopic response with EBL.

Gastric vascular abnormalities: diagnosis and management

PURPOSE OF REVIEW

Gastric vascular abnormalities are a well known cause of gastrointestinal bleeding. Due to their recurrent bleeding tendency and potential to cause life-threatening blood loss, gastric vascular abnormalities can result in significant morbidity and cost.

RECENT FINDINGS

There have been novel advances in medical and endoscopic management of gastric vascular lesions. New data suggest that endoscopic band ligation and ablation may be comparable, or even superior, to argon plasma coagulation (APC) for management of gastric antral vascular ectasia (GAVE). A creative, highly sensitive and specific computer-assisted tool has been developed to facilitate reading video capsule endoscopies for the detection of angiodysplasias, paving the way for artificial intelligence incorporation in vascular lesions diagnostics. Over-the-scope clipping is a relatively new technology that shows promising results in controlling bleeding from Dieulafoy's lesions.

SUMMARY

In this article, we will broadly review the management of the most prevalent gastric vascular lesions, focusing on the most recent areas of research.