Watermelon stomach in the CREST syndrome

Influences of etiology and endoscopic appearance on the long-term outcomes of gastric antral vascular ectasia

BACKGROUND

Gastric antral vascular ectasia (GAVE) has diverse associations and presumed causes, which include liver cirrhosis, chronic kidney disease, and autoimmune disease. This heterogeneity of underlying disorders suggests that the pathogenesis of GAVE may be variable.

AIM

To compare the clinical features and long-term outcomes of GAVE according to endoscopic patterns and etiologies.

METHODS

The medical records and endoscopic images of 23 consecutive patients diagnosed with GAVE by endoscopy at Yeungnam University Hospital from January 2006 to December 2020 were retrospectively reviewed. Patients were allocated to cirrhosis (16 patients) and non-cirrhosis groups (7 patients). GAVE subtypes, as determined by endoscopy, were categorized as punctate (a diffuse, honeycomb-like appearance, 17 patients) or striped (a linear, watermelon-like appearance, 6 patients).

RESULTS

All GAVE patients with cirrhosis (16/16, 100%) had a punctate pattern by endoscopy, whereas the majority of patients (6/7, 85.7%) without cirrhosis had a striped pattern (P < 0.001). Overt GAVE bleeding (10/23, 43%) was significantly more common in the non-cirrhosis group than in the cirrhosis group (6/7, 85.7% vs 4/16, 25.0%; P = 0.019), and more common in the striped group than in the punctate group (5/6, 83.3% vs 5/17, 29.4%; P = 0.052). However, mean numbers of admissions due to GAVE bleeding and argon plasma coagulation (APC) sessions to address overt bleeding were similar in the cirrhosis and non-cirrhosis groups and in the punctate and striped groups. All patients with GAVE bleeding were successfully treated by APC, and no patient died from GAVE-related blood loss during a median follow-up of 24 mo.

CONCLUSION

Punctate-type GAVE is strongly associated with liver cirrhosis, and GAVE patients without cirrhosis tend to be more prone to overt bleeding. However, the presence of cirrhosis and endoscopic patterns did not influence long-term clinical courses or outcomes in cases of overt bleeding.

Predictors of blood transfusion and in-hospital outcomes in patients with gastric antral vascular ectasia (GAVE): a nationwide population-based analysis

Background

Gastric antral vascular ectasia (GAVE) is a rare cause of chronic non-variceal upper gastrointestinal (GI) bleeding and can turn into life-threatening bleed in some patients. Packed red blood cell (PRBC) transfusions are often required in these patients during hospitalization. We aimed to investigate the hospitalization outcomes and predictors of PRBC transfusions in patients with GAVE lesions.

Methods

Using the ICD-9-CM codes (537.82, 537.83), we queried the National Inpatient Sample (NIS) [2010-2014] to recognize hospitalized GAVE patients. A 1:2 random sample was obtained from the non-GAVE cohort and these groups were compared (GAVE vs. non-GAVE). The predictors of PRBC transfusion in GAVE cohort were analyzed with multivariate analysis by using SPSS Statistics 22.0.

Results

We included weighted 89,081 GAVE and 178,550 non-GAVE hospitalized patients. The GAVE patients were tended to be older, female and white. Significantly higher proportions of comorbidities such as congestive heart failure, diabetes, hypertension, hypothyroidism, liver disease, renal failure, Sjogren syndrome, systemic sclerosis and portal hypertension, etc. were present in these patients. The all-cause inpatient mortality was found to be 1.4%. The mean hospital charges and length of stay (LOS) per GAVE hospitalization were $36,059 and 4.63±5.3 days, respectively. A total of 6,276 (weighted 31,102) (34.9%) of these patients received at least one PRBC transfusion during hospitalization. Advanced age, multiple comorbidities, non-elective admissions, male gender, and African American race were the independent factors associated with higher chances of receiving PRBC transfusion.

Conclusions

Our analysis showed that hospitalized patients with GAVE lesions had lower overall mortality rate despite having multiple comorbidities. There was no difference in the LOS and hospital charges between the two cohorts. Nearly 35% of the GAVE patients received at least one PRBC transfusion.

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.

Gastric Antral Vascular Ectasia in Systemic Sclerosis: Current Concepts

Introduction. Gastric antral vascular ectasia (GAVE) is a rare entity with unique endoscopic appearance described as “watermelon stomach.” It has been associated with systemic sclerosis but the pathophysiological changes leading to GAVE have not been explained and still remain uncertain. Methods. Databases Medline, Scopus, Embase, PubMed, and Cochrane were searched for relevant papers. The main search words were “Gastric antral vascular ectasia,” “Watermelon Stomach,” “GAVE,” “Scleroderma,” and “Systemic Sclerosis.” Fifty-four papers were considered for this review. Results. GAVE is a rare entity in the spectrum of manifestations of systemic sclerosis with unknown pathogenesis. Most patients with systemic sclerosis and GAVE present with asymptomatic anemia, iron deficiency anemia, or heavy acute gastrointestinal bleeding. Symptomatic therapy and endoscopic ablation are the first-line of treatment. Surgical approach may be recommended for patients who do not respond to medical or endoscopic therapies. Conclusion. GAVE can be properly diagnosed and treated. Early diagnosis is key in the management of GAVE because it makes symptomatic therapies and endoscopic approaches feasible. A high index of suspicion is critical. Future studies and a critical review of the current findings about GAVE are needed to understand the role of this condition in systemic sclerosis.

16 Y/O Female with "Watermelon Stomach"?

Background. Gastric antral vascular ectasia (GAVE) also known as “watermelon stomach” (WS) is an uncommon cause of gastrointestinal (GI) blood loss. It typically presents in middle aged females. We are presenting a case of GAVE at an unusually early age with atypical symptoms. Case. A previously healthy 16 y/o Caucasian female presented to the ER with a one-month history of upper abdominal pain. Physical examination was benign except tenderness in the epigastric region. There were no significant findings on laboratory data. Upper endoscopy showed incidental findings of linear striae in the antrum indicative of GAVE but histology was equivocal. Discussion. GAVE is a poorly understood but treatable entity and an increasingly identifiable cause of chronic iron deficiency anemia or acute or occult upper GI bleeding. The pathophysiology of GAVE remains unclear. It is an endoscopic finding characterized by longitudinal columns of tortuous red ectatic vessels (watermelon stripes), pathognomonic for WS. Treatment options include endoscopic, pharmacologic, and surgical approaches. Failure to recognize GAVE can result in delayed treatment for years. Our patient with GAVE was unusually young and was diagnosed incidentally. Due to lack of anemia on laboratory examination we elected to monitor her clinically for any future development of anemia.

Gastric antral vascular ectasia: case report and review of the literature

Gastric antral vascular ectasia is the source of up to 4% of nonvariceal upper gastrointestinal bleeding. It can present with occult bleeding requiring transfusions or with acute gastrointestinal bleeding. It is associated with significant morbidity and mortality and has been associated with such underlying chronic diseases as scleroderma, diabetes mellitus, and hypertension. Approximately 30% of cases are associated with cirrhosis. We report two cases of gastric antral vascular ectasia with two strikingly different endoscopic appearances. We further describe the clinical, endoscopic, histologic, and therapeutic aspects of this entity.

Watermelon stomach in systemic sclerosis: its incidence and management

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.

Watermelon stomach: pathophysiology, diagnosis, and management

Watermelon Stomach (WS) has been increasingly recognized as an important cause of occult gastrointestinal blood loss. Clinically, patients develop significant iron deficiency anemia and are frequently transfusion dependent. The histologic hallmark of WS is superficial fibromuscular hyperplasia of gastric antral mucosa with capillary ectasia and microvascular thrombosis in the lamina propria. Endoscopic findings of the longitudinal antral folds containing visible columns of tortuous red ectatic vessels (watermelon stripes) are pathognomonic for WS. Trauma to the mucosal epithelium overlying engorged vessels by gastric acid or intraluminal food results in bleeding. Treatment options for WS include endoscopic, pharmacologic, and surgical approaches. Endoscopic therapy, including contact and non-contact thermal ablations of the angiodysplastic lesions, is the mainstay of conservative therapy. However, many patients fail endoscopic therapy and develop recurrent acute and chronic GI bleeding episodes. Surgical resection may be the only reliable method for achieving a cure and eliminating transfusion dependency. Traditionally, surgery was used only as a last resort after patients failed prolonged medical and/or endoscopic therapy. However, based on the experience garnered from the literature we recommend a more aggressive surgical approach in patients who fail a short trial of endoluminal therapy.

Watermelon stomach following and preceding systemic sclerosis

OBJECTIVES

To report two patients with watermelon stomach associated with systemic sclerosis (SSc) and review the literature on that subject.

METHODS

We describe the clinical presentation, course and outcome of our two patients and reviewed the medical literature registered in the MedLine PubMed database from 1966 to 1999 by using the key words watermelon stomach, gastric antral vascular ectasia, systemic sclerosis, scleroderma.

RESULTS

The two patients presented with microcytic hypochromic anemia. Esophagogastroscopy showed multiple linear vascular malformations in the antrum compatible with watermelon stomach. They responded to Nd-Yag laser therapy with resolution of the lesions and improvement of the anemia. Patient 1 had a history of diffuse SSc while patient 2 developed limited SSc 2 years after the diagnosis of watermelon stomach. A literature review disclosed 16 documented case reports of watermelon stomach associated with SSc, 14 of whom were women. In most cases, watermelon stomach occurred in patients with established SSc but in some it antedated it by several years. In many cases, other autoimmune syndromes such as hypothyroidism, primary biliary cirrhosis, and Sjögren's syndrome were present. The presenting symptom was iron deficiency anemia, which in 11 cases was severe enough to require blood transfusions. Nine patients were successfully treated with several transendoscopic treatments, four required surgical intervention, and in three treatment was not specified.

CONCLUSION

Although watermelon stomach is a rare syndrome, it is recognized as a cause of persistent bleeding in patients with SSc. Awareness of this condition may increase its recognition and treatment.

Scleroderma and the watermelon stomach

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