Endoscopic band ligation: a novel therapy for bleeding gastric antral vascular ectasia

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.

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.

Gastric Antral Vascular Ectasia: A Case Report and Literature Review

Gastric antral vascular ectasia (GAVE) is a rare but an important cause of upper gastrointestinal bleeding (UGIB) and commonly presents as occult bleeding that manifests as iron deficiency anemia (IDA). GAVE is commonly associated with chronic illnesses, most frequently liver cirrhosis and connective tissue diseases. The pathogenesis of GAVE is still obscure, and many hypotheses such as mechanical stress, hormonal factors, and autoimmune factors, have been proposed. Upper gastrointestinal endoscopy has a major role in the diagnosis and treatment of GAVE.

Endoscopic Treatment for Gastric Antral Vascular Ectasia: Current Options

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.

Endoscopic management of nonvariceal, nonulcer upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is the most common emergency condition in gastroenterology. Although peptic ulcer and esophagogastric varices are the predominant causes, other conditions account for up to 50% of UGIBs. These conditions, among others, include angiodysplasia, Dieulafoy and Mallory-Weiss lesions, gastric antral vascular ectasia, and Cameron lesions. Upper GI cancer as well as lesions of the biliary tract and pancreas may also result in severe UGIB. This article provides an overview of the endoscopic management of these lesions, including the role of novel therapeutic modalities such as hemostatic powder and over-the-scope-clips.

Endoscopic band ligation: beyond prevention and management of gastroesophageal varices

Endoscopic band ligation (EBL) is the preferred endoscopic technique for the endoscopic treatment of acute esophageal variceal bleeding. EBL has also been used to treat nonvariceal bleeding. Recently, Han et al demonstrated that EBL can be a feasible and safe alternate technique for the management of iatrogenic gastric perforation especially in cases in which closure with endoclips is difficult. EBL is technically simpler to perform than other methods and provides a good view of the lesions under direct pressure and suction from the transparent ligation cap. EBL can be used even if the diameter of the perforation is greater than 10 mm or if there is a severe tangential angle. In this commentary, we discuss the efficacy and safety of EBL for the closure of iatrogenic gastrointestinal perforation. We also discuss the advantages and disadvantages of EBL for the treatment of nonvariceal bleeding.

Band ligation of gastric antral vascular ectasia is a safe and effective endoscopic treatment

BACKGROUND AND AIM

Gastric antral vascular ectasia (GAVE) or 'watermelon stomach' is a rare and often misdiagnosed cause of occult upper gastrointestinal bleeding. Treatment includes conservative measures such as transfusion and endoscopic therapy. A recent report suggests that endoscopic band ligation (EBL) offers an effective alternative treatment. The aim of the present study is to demonstrate our experiences with this novel technique, and to compare argon plasma coagulation (APC) with EBL in terms of safety and efficacy.

METHODS

A retrospective analysis of all endoscopies with a diagnosis of GAVE was carried out between 2004 and 2010. Case records were examined for information pertaining to the number of procedures carried out, mean blood transfusions, mean hemoglobin, and complications.

RESULTS

A total of 23 cases of GAVE were treated. The mean age was 73.9 (55-89) years. Female to male ratio was 17:6 and mean follow up was 26 months. Eight patients were treated with EBL with a mean number of treatments of 2.5 (1-5). This resulted in a statistically significant improvement in the endoscopic appearance and a trend towards fewer transfusions. Of the eight patients treated with EBL, six (75%) patients had previously failed APC treatment despite having a mean of 4.7 sessions. Band ligation was not associated with any short- or medium-term complications. The 15 patients who had APC alone had a mean of four (1-11) treatments. Only seven (46.7%) of these patients had any endoscopic improvement with a mean of four sessions.

CONCLUSIONS

EBL represents a safe and effective treatment for GAVE.

Massive gastric antral vascular ectasia successfully treated by endoscopic band ligation as the initial therapy

Gastric antral vascular ectasia (GAVE) accounted for 4% of non-variceal gastrointestinal hemorrhage. Even though unclear pathogenesis, GAVE often associated with chronic renal failure, autoimmune diseases and cirrhosis. Asymptomatic lesions were reasonably not to treated. The treatment options for GAVE are non-endoscopic and endoscopic treatments. For the pharmacological treatment, some success were reported for the use of octreotide, thalidomide and tranexamic acid. While the endoscopic treatment is the mainstay for treatment of symptomatic lesions. The endoscopic ablative therapies such as argon plasma coagulation was reported with good clinical outcomes. However, these treatment options had some limitation due to the need of special equipment and multiple sessions needed to control the bleeding. We reported another treatment option using the routine-achievable instrument such as endoscopic band ligation as an initial treatment which also provided a good treatment outcome and less sessions.

Diagnosis and management of gastric antral vascular ectasia

Gastric antral vascular ectasia (GAVE) is an uncommon but often severe cause of upper gastrointestinal (GI) bleeding, responsible of about 4% of non-variceal upper GI haemorrhage. The diagnosis is mainly based on endoscopic pattern and, for uncertain cases, on histology. GAVE is characterized by a pathognomonic endoscopic pattern, mainly represented by red spots either organized in stripes radially departing from pylorus, defined as watermelon stomach, or arranged in a diffused-way, the so called honeycomb stomach. The histological pattern, although not pathognomonic, is characterized by four alterations: vascular ectasia of mucosal capillaries, focal thrombosis, spindle cell proliferation and fibrohyalinosis, which consist of homogeneous substance around the ectatic capillaries of the lamina propria. The main differential diagnosis is with Portal Hypertensive Gastropathy, that can frequently co-exists, since about 30% of patients with GAVE co-present a liver cirrhosis. Autoimmune disorders, mainly represented by Reynaud’s phenomenon and sclerodactyly, are co-present in about 60% of patients with GAVE; other autoimmune and connective tissue disorders are occasionally reported such as Sjogren’s syndrome, systemic lupus erythematosus, primary biliary cirrhosis and systemic sclerosis. In the remaining cases, GAVE syndrome has been described in patients with chronic renal failure, bone marrow transplantation and cardiac diseases. The pathogenesis of GAVE is still obscure and many hypotheses have been proposed such as mechanical stress, humoural and autoimmune factors and hemodynamic alterations. In the last two decades, many therapeutic options have been proposed including surgical, endoscopic and medical choices. Medical therapy has not clearly shown satisfactory results and surgery should only be considered for refractory severe cases, since this approach has significant mortality and morbidity risks, especially in the setting of portal hypertension and liver cirrhosis. Endoscopic therapy, particularly treatment with Argon Plasma Coagulation, has shown to be as effective and also safer than surgery, and should be considered the first-line treatment for patients with GAVE-related bleeding.

Endoscopic band ligation versus argon plasma coagulation for gastric antral vascular ectasia associated with liver diseases

AIM

The aim of the present study was to evaluate the clinicopathological features and the efficacy of endoscopic treatments in treating gastric antral vascular ectasia (GAVE) in association with liver diseases.

METHODS

Thirty-four patients with the characteristic endoscopic findings of GAVE were enrolled. Endoscopic treatments were carried out for all 34 patients, including argon plasma coagulation (APC) in 22 patients and endoscopic band ligation (EBL) in 12 patients.

RESULTS

All 34 patients had iron-deficiency anemia and 21 patients also had a history of tarry stools. The underlying pathologies of chronic liver diseases were liver cirrhosis in 26 patients, liver cirrhosis associated with hepatocellular carcinoma in six, and idiopathic portal hypertension in two. The liver function was classified by Child-Pugh classification: class A (n=6), class B (n=21), and class C (n=7). Antral motility was frequent and intense in all 34 GAVE patients. In the 22 patients who received APC, endoscopies revealed the recurrence of GAVE in 15 patients requiring further treatment by APC (recurrence rate, 68.2%). Seven patients died during the follow-up period, including two cases with bleeding-related deaths. In the 12 patients who received EBL, endoscopies revealed the recurrence of GAVE in one patient requiring further treatment by EBL (recurrence rate, 8.3%). Two patients died during the follow-up period, neither were bleeding-related deaths.

CONCLUSIONS

The results suggest that GAVE is related to severe liver damage and portal hypertension. APC has a high recurrence rate of GAVE in the medium term after treatment. EBL may be useful as a treatment for GAVE.

Endoscopic band ligation for refractory gastric antral vascular ectasia associated with liver cirrhosis

An 84-year-old woman with unknown liver cirrhosis was admitted to our hospital in October 2008 with anemia due to recurrent gastric antral vascular ectasia (GAVE). At 78 years of age, argon plasma coagulation (APC) was performed for GAVE, and between 79 and 83 years of age, APC was carried out five times for recurrent episodes of GAVE presenting as anemia. Upon hospitalization, she was found to have anemic conjunctivae and the laboratory findings were red blood cells 245 × 10(4)/mm(3) and hemoglobin 7.7 g/dL. During this period, endoscopic band ligation (EBL) was performed for the recurrent refractory GAVE. EBL was first applied to the most distal antrum, and subsequent EBLs were performed more proximally. Two weeks after initial EBL treatment, endoscopy revealed both ulcers and shrinking of GAVE in the stomach. Fourteen months later, no further recurrence of GAVE was observed by endoscopy. This patient had no episodes of bleeding during the 20 month period since she was treated with EBL, and has a hemoglobin value of 10.1 g/dL. The histologic changes that occur with GAVE exist in the mucosal and submucosal region of the stomach; therefore, EBL may be effective for refractory GAVE because of obliterating submucosal vascular plexus.

Treatment of gastric antral vascular ectasia (watermelon stomach) with endoscopic band ligation

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.