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Khalifa A, Rockey DC. Role of Endoscopy in the Diagnosis, Grading, and Treatment of Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia. Gastrointest Endosc Clin N Am 2024; 34:263-274. [PMID: 38395483 DOI: 10.1016/j.giec.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
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.
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Affiliation(s)
- Ali Khalifa
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA.
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Maye JA, Baker O, Sheikh N. Resolution of gastric antral vascular ectasia following cessation of imatinib. BMJ Case Rep 2024; 17:e257620. [PMID: 38388203 PMCID: PMC10884209 DOI: 10.1136/bcr-2023-257620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
A female patient in her 80s presented with chronic iron-deficiency anaemia secondary to gastric antral vascular ectasia (GAVE), despite repeated endoscopic treatment. Her medical history was notable for chronic myeloid leukaemia, for which she took imatinib. Due to a possible association between imatinib and GAVE described in a small number of case reports, cessation of imatinib was trialled. This led to a significant improvement in the patient's anaemia and resolution of GAVE on repeat endoscopy. GAVE is an uncommon cause of gastrointestinal bleeding, the aetiology of which is uncertain. This report describes an approach to the differential diagnosis of chronic iron-deficiency anaemia and an overview of GAVE syndrome. It illustrates the benefit of broadening the differential when the diagnosis is uncertain and the utility of case reports in informing the differential diagnosis.
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Affiliation(s)
- James A Maye
- Medicine, West Suffolk Hospital, Bury Saint Edmunds, UK
| | - Olivia Baker
- Medicine, West Suffolk Hospital, Bury Saint Edmunds, UK
| | - Nadim Sheikh
- Gastroenterology, West Suffolk Hospital, Bury Saint Edmunds, UK
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Nair R, Elsaygh J, Zaher A, Fragner M, Perk G. Native Aortic Valve Endocarditis Secondary to Gastric Antral Vascular Ectasia Manipulation During Endoscopic Argon Plasma Coagulation. Cureus 2024; 16:e53930. [PMID: 38465074 PMCID: PMC10924696 DOI: 10.7759/cureus.53930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 03/12/2024] Open
Abstract
Gastric antral vascular ectasia (GAVE) is an uncommon cause of upper gastrointestinal (GI) bleeds. Due to the high vascularity of the region, transient bacteremia due to manipulation of the GI tract can very rarely cause the translocation of bacteria. We present a rare case in which endoscopic manipulation to treat GAVE led to native valve infective endocarditis (IE). Our patient had a prior history of GAVE and presented with worsening dizziness and shortness of breath (SOB). After an esophagogastroduodenoscopy (EGD) and subsequent argon plasma coagulation (APC) for active preantral bleeding, the patient was noted to have repeated fevers, a new cardiac murmur, and positive blood cultures for Staphylococcus epidermidis, leading to a diagnosis of native infective endocarditis. With high clinical suspicion and early recognition of a new cardiac murmur, a transesophageal echocardiogram (TEE) was key in identifying vegetation. This case highlights the importance of combining history, a physical exam, and diagnostic lab tests and imaging to identify endocarditis. Management included two months of intravenous (IV) vancomycin and repeat TEE for close monitoring of vegetation improvement.
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Affiliation(s)
- Ranjit Nair
- Internal Medicine, New York-Presbyterian Brooklyn Methodist Hospital, New York City, USA
| | - Jude Elsaygh
- Internal Medicine, New York-Presbyterian Brooklyn Methodist Hospital, New York City, USA
| | - Anas Zaher
- Internal Medicine, New York-Presbyterian Brooklyn Methodist Hospital, New York City, USA
| | - Michael Fragner
- Internal Medicine, New York-Presbyterian Brooklyn Methodist Hospital, New York City, USA
| | - Gila Perk
- Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, New York City, USA
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Che CC, Shiu SI, Ko CW, Tu YK, Chang CH. Comparisons Between Endoscopic Band Ligation, Radiofrequency Ablation and Endoscopic Thermal Therapy for Gastric Antral Vascular Ectasia: A Meta-Analysis. Dig Dis Sci 2023; 68:3534-3541. [PMID: 37490152 PMCID: PMC10444674 DOI: 10.1007/s10620-023-08028-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 04/25/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Endoscopic band ligation (EBL) and radiofrequency ablation (RFA) have emerged as alternative therapies of gastric antral vascular ectasia (GAVE) in addition to endoscopic thermal therapy (ETT), but the optimum choice remains inconclusive. AIM We conducted a meta-analysis in order to compare these three treatments for GAVE. METHODS We searched the electronic databases of PubMed, Embase and Cochrane Central Register of Controlled Trials without any language restrictions and also performed a manual literature search of bibliographies located in both retrieved articles and published reviews for eligible publications prior to December 8, 2021. We included comparative trials which had evaluated the efficacy and safety of interventions in adults (aged ≥ 18 years) diagnosed with symptomatic GAVE and was confirmed according to clinical backgrounds and upper gastrointestinal endoscopy. We included reports that compared three interventions, ETT, EBL, and RFA. The study was comprised of adults diagnosed with GAVE and focused on overall mortality, bleeding cessation, endoscopic improvement, complications, hospitalization, hemoglobin improvement, number of sessions and transfusion requirements. RESULTS Twelve studies were performed involving a total of 571 participants for analysis. When compared with ETT, EBL achieved better bleeding cessation (OR 4.48, 95% CI 1.36-14.77, p = 0.01), higher hemoglobin improvement (MD 0.57, 95% CI 0.31-0.83, p < 0.01) and lower number of sessions (MD - 1.44, 95% CI - 2.54 to - 0.34, p = 0.01). Additionally, EBL was superior to ETT in endoscopic improvement (OR 6.00, 95% CI 2.26-15.97, p < 0.01), hospitalization (MD - 1.32, 95% CI - 1.91 to - 0.74, p < 0.01) and transfusion requirement (MD - 2.66, 95% CI - 4.67 to - 0.65, p = 0.01) with statistical significance, with the exception of mortality (OR 0.58, 95% CI 0.19-1.77, p = 0.34) and complication rate (OR 5.33, 95% CI 0.58-48.84, p = 0.14). CONCLUSION For GAVE, we suggest that EBL be initially recommended, and APC and RFA be used as alternative treatment choices based upon a very low quality of evidence.
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Affiliation(s)
- Cheng-Che Che
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Sz-Iuan Shiu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Evidence-Based Practice and Policymaking Committee, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chung-Wang Ko
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Heath Data Research Center, National Taiwan University, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital and School of Dentistry, National Taiwan University, Taipei, Taiwan
| | - Chung-Hsin Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
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Misumi Y, Takeuchi M, Kishino M, Kudo Y, Nonaka K. A case of gastric antral vascular ectasia in which PuraStat, a novel self‐assembling peptide hemostatic hydrogel, was effective. DEN OPEN 2023; 3:e183. [DOI: 10.1002/deo2.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/04/2022] [Accepted: 10/22/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Yoshitsugu Misumi
- Department of Digestive Endoscopy Tokyo Women's Medical University Hospital Tokyo Japan
| | - Miharu Takeuchi
- Department of Digestive Endoscopy Tokyo Women's Medical University Hospital Tokyo Japan
| | - Maiko Kishino
- Department of Digestive Endoscopy Tokyo Women's Medical University Hospital Tokyo Japan
| | - Yoshimichi Kudo
- Department of Pediatric Cardiology and Adult Congenital Cardiology Tokyo Women's Medical University Hospital Tokyo Japan
| | - Kouichi Nonaka
- Department of Digestive Endoscopy Tokyo Women's Medical University Hospital Tokyo Japan
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Gairing SJ, Schleicher EM, Müller L, Labenz C, Darstein F, Grimm D, Sivanathan V, Weinmann A, Wörns MA, Kloeckner R, Pitton MB, Thieringer F, Rahman KF, Galle PR, Schattenberg JM, Foerster F. Bevacizumab in combination with octreotide rescues a patient with liver cirrhosis, GAVE syndrome and refractory hemorrhage - a case report. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:275-279. [PMID: 36379462 DOI: 10.1055/a-1959-2660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Gastric antral vascular ectasia (GAVE) syndrome is a rare but often challenging etiology of upper gastrointestinal bleeding (UGIB).We report on a 60-year-old patient with liver cirrhosis, GAVE syndrome and recurrent and refractory GAVE-related UGIB. During a 5-month hospital stay, the patient required a total of 82 packed red blood cells (pRBCs) and 23 gastroscopies. All endoscopic approaches, including multiple argon plasma coagulation and band ligation sessions, remained unsuccessful. Antrectomy was waived because of the high perioperative mortality risk in Child-Pugh B liver cirrhosis. TIPS insertion also failed to control the bleeding. Only continuous intravenous octreotide infusion slowed the bleeding, but this forced the patient to be hospitalized. After 144 inpatient days, administration of subcutaneous octreotide allowed the patient to be discharged. However, the patient continued to require two pRBCs every 2-3 weeks. Based on recently published data, we treated the patient with bevacizumab (anti-VEGF antibody) off-label at a dose of 7.5 mg/kg body weight every three weeks in nine single doses over six months. Since the first administration, the patient has remained transfusion-free, has not required hospitalization, and leads an active life, working full-time. He remains on octreotide, which has been reduced but not yet discontinued. Additionally, no adverse events were observed.Thus, in patients with liver cirrhosis and refractory GAVE-related hemorrhage, bevacizumab combined with subcutaneous octreotide should be considered as an effective and durable pharmacological treatment option.
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Affiliation(s)
- Simon Johannes Gairing
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eva Maria Schleicher
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Lukas Müller
- Department of Diagnostic and Interventional Radiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Felix Darstein
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Daniel Grimm
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Visvakanth Sivanathan
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Arndt Weinmann
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Marcus-Alexander Wörns
- Department of Gastroenterology, Hematology, Oncology and Endocrinology, Hospital Dortmund, Dortmund, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michael B Pitton
- Department of Diagnostic and Interventional Radiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Florian Thieringer
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Khan Fareed Rahman
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Peter Robert Galle
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jörn M Schattenberg
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Friedrich Foerster
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
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Itagaki H, Suzuki K, Endo T. A Case of Refractory Gastric Antral Vascular Ectasia Treated Successfully With Distal Gastrectomy and Billroth II Reconstruction. Cureus 2023; 15:e34875. [PMID: 36923192 PMCID: PMC10010929 DOI: 10.7759/cureus.34875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2023] [Indexed: 02/13/2023] Open
Abstract
Gastric antral vascular ectasia is a rare cause of upper gastrointestinal bleeding and an important cause of transfusion dependence. Although surgery should be considered when patients with gastric antral vascular ectasia become transfusion-dependent even after endoscopic treatment, surgery for such patients with cirrhosis on dialysis has not been reported. Our patient, a 62-year-old man with a history of cirrhosis and chronic kidney failure, experienced recurrent bloody stool. Upper endoscopic findings indicated a diagnosis of gastric antral vascular ectasia; therefore, we initiated therapy with argon plasma coagulation. Anemia developed, and despite a second argon plasma coagulation treatment, it remained difficult to control. During the six weeks of hospitalization, the patient received more than 40 units of red blood cells. The gastroenterologist determined that further treatment with argon plasma coagulation would increase the risk of gastric perforation; therefore, we performed distal gastrectomy with Billroth II reconstruction. The patient was discharged from the hospital 15 days after surgery and had no signs of anemia for more than one year after discharge. The case of our patient shows that although endoscopic therapy is the usual treatment for gastric antral vascular ectasia, surgery should be considered when anemia is difficult to control.
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Affiliation(s)
- Hideya Itagaki
- Department of Emergency and Disaster Medicine, Tohoku Medical and Pharmaceutical University Hospital, Miyagi, JPN
| | | | - Tomoyuki Endo
- Department of Emergency and Disaster Medicine, Tohoku Medical and Pharmaceutical University Hospital, Miyagi, JPN
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Lageju N, Uprety P, Neupane D, Bastola S, Lama S, Panthi S, Gnawali A. Gastric antral vascular ectasia (Watermelon stomach); an unusual cause of upper gastrointestinal bleeding in elderly: A case report. Ann Med Surg (Lond) 2022; 82:104733. [PMID: 36268406 PMCID: PMC9577822 DOI: 10.1016/j.amsu.2022.104733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 09/11/2022] [Accepted: 09/18/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Gastric antral vascular ectasia (GAVE) is an unusual cause of upper gastrointestinal (GI) bleeding in an elderly patient. Case presentation A 73-year-old female with erosive gastritis, hypertension, and unstable angina arrived at the emergency department with shortness of breath, easy fatigability, and melaena. Physical examination indicated pallor but no signs of distress, with an unremarkable systemic examination. Routine blood testing indicated anemia. The patient underwent upper gastrointestinal endoscopy, which revealed linear red ectatic vessels radiating from the antrum towards the body. A diagnosis of GAVE was made. Blood transfusions and argon plasma coagulation were undertaken. Clinical discussion This condition is an uncommon cause of upper GI bleeding with the antrum being the most prevalent site. The pathophysiology of GAVE is yet unknown, however, many hypotheses have been postulated. GAVE is frequently misdiagnosed as gastritis. GAVE treatment comprises initial resuscitation and symptomatic treatment with intravenous fluids and blood products. Endoscopy has increasingly been the first-line therapeutic option for GAVE in recent years, including argon plasma coagulation. Conclusion The diagnosis of gastric antral vascular ectasia is frequently overlooked during upper GI endoscopy, despite the fact that it should always be explored, especially in cases of unexplained GI bleeding in the elderly. An unusual cause of upper gastrointestinal bleeding in an elderly patient. Frequently misdiagnosed as gastritis. Linear red ectatic vessels radiating from gastric antrum towards the body. Argon plasma coagulation is a good treatment modality.
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Affiliation(s)
- Nimesh Lageju
- B. P. Koirala of Institute of Health Sciences, Dharan, Nepal
| | - Pratik Uprety
- B. P. Koirala of Institute of Health Sciences, Dharan, Nepal
| | - Durga Neupane
- B. P. Koirala of Institute of Health Sciences, Dharan, Nepal
| | - Satish Bastola
- B. P. Koirala of Institute of Health Sciences, Dharan, Nepal
| | - Suhel Lama
- B. P. Koirala of Institute of Health Sciences, Dharan, Nepal
| | - Sagar Panthi
- B. P. Koirala of Institute of Health Sciences, Dharan, Nepal
| | - Arun Gnawali
- Department of Gastroenterology, Tribhuvan University Teaching Hospital, Maharajgunj, Nepal
- Corresponding author.
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Rajabnia M, Hatami B, Ketabi Moghadam P, Mohammadi M, Rafizadeh M, Mangeli F, Fathi M, Jahanian A. Comparison of portal hypertensive gastropathy and gastric antral vascular ectasia: an update. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2022; 15:204-218. [PMID: 36311963 PMCID: PMC9589138 DOI: 10.22037/ghfbb.v15i3.2561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/01/2022] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Mohsen Rajabnia
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Behzad Hatami
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pardis Ketabi Moghadam
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahsa Mohammadi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mitra Rafizadeh
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Forogh Mangeli
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mobin Fathi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Jahanian
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Peng M, Guo X, Yi F, Romeiro FG, Mancuso A, Qi X. Pharmacotherapy for the Treatment of Gastric Antral Vascular Ectasia: A Narrative Review. Adv Ther 2021; 38:5065-5077. [PMID: 34524644 DOI: 10.1007/s12325-021-01912-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/31/2021] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Mengyuan Peng
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China
- Postgraduate College, Jinzhou Medical University, Jinzhou, People's Republic of China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China
| | - Fangfang Yi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China
| | - Fernando Gomes Romeiro
- Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Av. Prof. Mário Rubens Guimarães Montenegro, s/n, Distrito de Rubião Jr., Botucatu, SP, 18608917, Brazil
| | - Andrea Mancuso
- Medicina Interna 1, ARNAS Civico, Di Cristina, Benfratelli, Piazzale Leotta 4, Palermo, Italy
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China.
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