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Kwon HJ, Lee SH, Cho JH. Influences of etiology and endoscopic appearance on the long-term outcomes of gastric antral vascular ectasia. World J Clin Cases 2022; 10:6050-6059. [PMID: 35949841 PMCID: PMC9254169 DOI: 10.12998/wjcc.v10.i18.6050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/31/2022] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Hyo Jin Kwon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
| | - Si Hyung Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
| | - Joon Hyun Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu 42415, South Korea
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Kajihara Y. An Unusual Cause of Anemia in a Middle-Aged Woman. Chonnam Med J 2021; 57:221-222. [PMID: 34621644 PMCID: PMC8485092 DOI: 10.4068/cmj.2021.57.3.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Yusaku Kajihara
- Department of Gastroenterology, Fuyoukai Murakami Hospital, Aomori, Japan
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McCarty TR, Hathorn KE, Chan WW, Jajoo K. Endoscopic band ligation in the treatment of gastric antral vascular ectasia: a systematic review and meta-analysis. Endosc Int Open 2021; 9:E1145-E1157. [PMID: 34222641 PMCID: PMC8216786 DOI: 10.1055/a-1401-9880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/15/2021] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
- Thomas R. McCarty
- Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
| | - Kelly E. Hathorn
- Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
| | - Walter W. Chan
- Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
| | - Kunal Jajoo
- Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
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Kichloo A, Solanki D, Singh J, Dahiya DS, Lal D, Haq KF, Aljadah M, Gandhi D, Solanki S, Khan HMA. Gastric Antral Vascular Ectasia: Trends of Hospitalizations, Biodemographic Characteristics, and Outcomes With Watermelon Stomach. Gastroenterology Res 2021; 14:104-111. [PMID: 34007352 PMCID: PMC8110233 DOI: 10.14740/gr1380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 04/08/2021] [Indexed: 01/10/2023] Open
Abstract
Background Gastric antral vascular ectasia (GAVE) syndrome is a rare but significant cause of acute or chronic gastrointestinal (GI) bleeding, particularly in the elderly. The primary objective of this study was to determine the biodemographic characteristics, adverse outcomes, and the impact of GAVE hospitalizations on the US healthcare system. Methods This retrospective database cross-sectional study used the National Inpatient Sample (NIS) from 2001 to 2011 to identify all adult hospitalizations with a primary discharge diagnosis of GAVE, with and without hemorrhage, using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Individuals less than 17 years of age were excluded from the study. The outcomes included biodemographic characteristics, comorbidity measures, and inpatient mortality and the burden of the disease on the US healthcare system in terms of healthcare cost and utilization. Results We noted an increase in the total hospitalizations for GAVE from 25,423 in 2001 to 44,787 in 2011. Furthermore, GAVE hospitalizations with hemorrhage rose from 19,168 in 2001 to 27,679 in 2011 while GAVE hospitalization without hemorrhage increased from 6,255 in 2001 to 17,108 in 2011. We also noted a female predominance, the proportional trend of which did not show significant difference from 2001 to 2011. For GAVE hospitalizations, the inpatient mortality decreased from 2.20% in 2001 to 1.73% in 2011. However, the cost of hospitalization increased from $11,590 in 2001 to $12,930 in 2011. After adjusting for possible confounders, we observed that the presence of hemorrhage in GAVE hospitalizations was associated with an increased risk of mortality (odds ratio (OR): 1.27; 95% confidence interval (CI): 1.1 - 1.46; P = 0.001). Conclusions For the study period, the total number of GAVE hospitalizations increased with an increase noted in the proportion of GAVE hospitalizations without bleeding, reflecting an improvement in diagnostic and therapeutic techniques. Although inpatient mortality for GAVE slightly decreased, we noted a significant increase in the cost of care likely secondary to increased use of advanced and expensive interventions.
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Affiliation(s)
- Asim Kichloo
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Dhanshree Solanki
- Department of Internal Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Jagmeet Singh
- Department of Internal Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Darshan Lal
- Department of Internal Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Khwaja Fahad Haq
- Division of Gastroenterology, Henry Ford Hospital, Detroit, MI, USA
| | - Michael Aljadah
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Darshan Gandhi
- Department of Radiology, Hartford Healthcare, Hartford, CT, USA
| | - Shantanu Solanki
- Department of Internal Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
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Aveiro M, Rodrigues T, Rabadão T, Ferreira F, Teixeira M, Oliveira A, Vasconcelos I. The Use of Thalidomide in Severe Refractory Anaemia Due to Gastric Antral Vascular Ectasia (GAVE) in Cirrhosis? Eur J Case Rep Intern Med 2021; 7:002099. [PMID: 33457370 DOI: 10.12890/2020_002099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/28/2020] [Indexed: 01/17/2023] Open
Abstract
Gastric antral vascular ectasia (GAVE) is a rare cause of upper gastrointestinal bleeding associated with cirrhosis. The first-line treatment is endoscopic therapy with argon plasma coagulation (APC). There is a high recurrence rate, but some evidence suggests that thalidomide could play an important role in controlling refractory anaemia due to GAVE. The authors present the case of a cirrhotic patient with a recent diagnosis of GAVE, who underwent multiple endoscopic treatments and blood transfusions because of haematemesis. The patient started thalidomide and 6 months later, there was no recurrence of haematemesis and haemoglobin levels were stable, with no reported adverse effects. LEARNING POINTS The chronic bleeding associated with gastric antral vascular ectasia (GAVE) presenting with cirrhosis is more severe than that associated with portal hypertensive gastropathy.Argon plasma coagulation remains the first-line treatment, but GAVE has a high recurrence rate.Thalidomide could be an effective and safe option for recurrent bleeding due to GAVE in patients with cirrhosis.
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Affiliation(s)
- Marcelo Aveiro
- Department of Internal Medicine, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Tatiana Rodrigues
- Department of Internal Medicine, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Tiago Rabadão
- Department of Internal Medicine, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Filipa Ferreira
- Department of Internal Medicine, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Mariana Teixeira
- Department of Internal Medicine, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Ana Oliveira
- Department of Internal Medicine, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Inês Vasconcelos
- Department of Family Medicine, USF Atlântico Norte, Gafanha da Nazaré, Portugal
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Pizzuto M, Ellul S, Shoukry M. Gastric antral vascular ectasia in children, rare presentation. BMJ Case Rep 2020; 13:13/11/e236896. [PMID: 33257371 DOI: 10.1136/bcr-2020-236896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 14-year-old boy, a known case of perinatal hypoxic cerebral palsy, presented to paediatric emergency with acute melaena and blood staining around feeding gastrostomy site. Physical examination revealed pallor, but no signs of distress with an unremarkable abdominal examination. Routine blood tests revealed normochromic. Abdominal ultrasound scan and Meckel's scan were unremarkable. The patient underwent examination under anaesthesia of the perianal area and joint upper and lower gastrointestinal endoscopy. Streak-like gastritis with no signs of active bleeding lesions were noted and patchy areas of colitis involving the descending and sigmoid colon and the rectum. All clinical findings and evidence-based diagnosis matched gastric antral vascular ectasia. He was successfully managed conservatively with elemental hydrolysed feeding formula.
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Ali SE, Benrajab KM, Cruz ACD. Outcome of gastric antral vascular ectasia and related anemia after orthotopic liver transplantation. World J Hepatol 2020; 12:1067-1075. [PMID: 33312430 PMCID: PMC7701976 DOI: 10.4254/wjh.v12.i11.1067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/04/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) is a significant complication of cirrhosis. Numerous medical, surgical, and endoscopic treatment modalities have been proposed with varied satisfactory results. In a few small studies, GAVE and associated anemia have resolved after orthotopic liver transplantation (OLT).
AIM To assess the impact of OLT on the resolution of GAVE and related anemia.
METHODS We retrospectively reviewed clinical records of adult patients with GAVE who underwent OLT between September 2012 and September 2019. Demographics and other relevant clinical findings were collected, including hemoglobin levels and upper endoscopy findings before and after OLT. The primary outcome was the resolution of GAVE and its related anemia after OLT.
RESULTS Sixteen patients were identified. Mean pre-OLT Hgb was 7.7 g/dL and mean 12 mo post-OLT Hgb was 11.9 g/dL, (P = 0.001). Anemia improved (defined as Hgb increased by 2g) in 87.5% of patients within 6 to 12 mo after OLT and resolved completely in half of the patients. Post-OLT esophagogastroduodenoscopy was performed in 10 patients, and GAVE was found to have resolved entirely in 6 of those patients (60%).
CONCLUSION Although GAVE and associated anemia completely resolved in the majority of our patients after OLT, GAVE persisted in a few patients after transplant. Further studies in a large group of patients are necessary to understand the causality of disease and to better understand the factors associated with the persistence of GAVE post-transplant.
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Affiliation(s)
- Saad Emhmed Ali
- Division of Hospital Medicine, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Karim M Benrajab
- Division of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY 40536, United States
| | - Anna Christina Dela Cruz
- Division of Digestive Diseases and Nutrition, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY 40536, United States
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Mujtaba S, Chawla S, Massaad JF. Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives. J Clin Med 2020; 9:jcm9020402. [PMID: 32024301 PMCID: PMC7074258 DOI: 10.3390/jcm9020402] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 01/30/2023] Open
Abstract
Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.
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Santos S, Bernardes C, Borges V, Ramos G. Gastric antral vascular ectasia (GAVE) and hereditary hemorrhagic telangiectasia (HHT): two different conditions, one treatment. Ann Hematol 2020; 99:367-9. [DOI: 10.1007/s00277-019-03845-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/12/2019] [Indexed: 10/25/2022]
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McCarty TR, Rustagi T. Comparative Effectiveness and Safety of Radiofrequency Ablation Versus Argon Plasma Coagulation for Treatment of Gastric Antral Vascular Ectasia: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2019; 53:599-606. [PMID: 29952856 DOI: 10.1097/MCG.0000000000001088] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS Although argon plasma coagulation (APC) is the current standard endoscopic treatment for gastric antral vascular ectasia (GAVE), radiofrequency ablation (RFA) has emerged as an attractive alternative. The aim of this study was to perform a systematic review and meta-analysis to evaluate the comparative effectiveness and safety of RFA and APC in the treatment of GAVE. MATERIALS AND METHODS Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases along with major gastroenterology annual meetings were performed through March 2017. Measured outcomes for comparative effectiveness and safety including improvement in hemoglobin levels, transfusion dependence, number of treatment sessions, complications, follow-up, and author-reported endoscopic success were compared among RFA and APC studies. RESULTS In total, 24 studies (n=508) involving APC and 9 studies (n=104) on RFA were included. Mean age of patients included was comparable in both groups (65.33±7.80 y for APC vs. 66.96±6.23 y for RFA; P=0.98). Pooled mean follow-up was significantly longer for APC compared with RFA (19.52±13.11 vs. 7.43±3.72 mo; P<0.001). In total, 47% of RFA patients were refractory to previous treatment with APC. RFA required fewer mean treatment sessions compared with APC (2.10 vs. 3.39, respectively; P<0.001). RFA resulted in fewer and less severe complications as compared with APC (1.92% vs. 5.12%, respectively; P<0.001). Although the reported endoscopic success was better with RFA compared with APC (97% vs. 66%; P<0.001), the posttreatment pooled hemoglobin increase and reduction in transfusion dependence was higher for APC compared with RFA [weighted mean difference 3.10 g/dL (95% confidence interval, 2.92-3.28) vs. 1.95 g/dL (95% confidence interval, 1.62-2.26); P<0.001; and 88% vs. 66%; P<0.001, for APC and RFA, respectively]. CONCLUSIONS There is limited long-term data on RFA for GAVE; however, available evidence suggests RFA has a comparable efficacy and tolerability compared with APC. In addition, RFA seems to be effective for APC-refractory GAVE patients. Future controlled trials are needed to directly compare treatment efficacy, long-term durability, safety, and cost-effectiveness between these interventions.
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McCarty TR, Rustagi T. New Indications for Endoscopic Radiofrequency Ablation. Clin Gastroenterol Hepatol 2018; 16:1007-1017. [PMID: 29081376 DOI: 10.1016/j.cgh.2017.10.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/06/2017] [Accepted: 10/10/2017] [Indexed: 02/07/2023]
Abstract
Radiofrequency ablation (RFA) is a well-established treatment for several benign, premalignant, and malignant disorders. Although the role of RFA has been clearly defined, new indications for luminal and extraluminal applications of endoscopic RFA-directed therapies have emerged. RFA has recently produced promising results in patients with a variety of gastrointestinal and hepatopancreatobiliary pathologies. For example, endoscopic RFA has been used to treat patients with gastric antral vascular ectasia, chronic radiation proctitis, malignant biliary strictures, and ampullary adenomas with intraductal extension. Furthermore, endoscopic ultrasound-guided RFA appears to be an effective, minimally invasive treatment for ablation of solid and cystic lesions-particularly in the pancreas. We review the newer indications for RFA and discuss potential limitations of endoscopic RFA.
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Affiliation(s)
- Thomas R McCarty
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico.
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Patel AA, Trindade AJ, Diehl DL, Khara HS, Lee TP, Lee C, Sethi A. Nitrous oxide cryotherapy ablation for refractory gastric antral vascular ectasia. United European Gastroenterol J 2018; 6:1155-1160. [PMID: 30288277 DOI: 10.1177/2050640618783537] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/24/2018] [Indexed: 12/16/2022] Open
Abstract
Background Argon plasma coagulation (APC) is typically the first-line therapy for gastric antral vascular ectasia (GAVE). However, many patients are refractory to APC ablation. Objective We examined the safety and efficacy of nitrous oxide CryoBalloon cryotherapy ablation for GAVE refractory to APC. Methods This is a retrospective review of patients with refractory GAVE treated with the CryoBalloon system. Technical success was defined as successful ablation of the visualized GAVE. Clinical success was defined by transfusion independence and percentage of GAVE that was eradicated. Results Twenty-three patients with GAVE were included, of whom 16 patients (70%) had two treatments with the CryoBalloon and seven patients (30%) had one treatment. Technical success was achieved in all patients. At six months, 19/23 (83%) were transfusion independent, while 20/23 (87%) had more than 75% of the GAVE eradicated. Patients were transfused an average of 1.8 units/month one year prior to cryotherapy and an average of 0.3 units/month up to six months post-cryotherapy (p < 0.001). The average increase in mean hemoglobin at six months was 2.55 g/dl. No acute or late adverse events were reported. Conclusions CryoBalloon ablation is an efficacious and safe modality for the treatment of GAVE. Prospective studies need to be conducted to determine comparative results to standard therapies.
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Affiliation(s)
- Anish A Patel
- Columbia University Medical Center, Division of Digestive and Liver Disease, New York, NY, USA
| | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - David L Diehl
- Department of Gastroenterology, Geisinger Medical Center, Danville, PA, USA
| | - Harshit S Khara
- Department of Gastroenterology, Geisinger Medical Center, Danville, PA, USA
| | - Tai-Ping Lee
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Calvin Lee
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Amrita Sethi
- Columbia University Medical Center, Division of Digestive and Liver Disease, New York, NY, USA
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Abstract
PURPOSE OF REVIEW This article aims to review current therapeutic endoscopic treatments available for the management of gastrointestinal bleeding related to cirrhosis. RECENT FINDINGS Endoscopic band ligation is an effective treatment for primary prophylaxis, acute bleeding, and secondary prophylaxis of esophageal varices as well as for acute bleeding and secondary prophylaxis of select gastric varices. Sclerotherapy is a treatment option for acute bleeding and secondary prophylaxis of esophageal varices when band ligation is technically difficult. Cyanoacrylate glue injection is an effective treatment for acute bleeding of gastric and ectopic varices. Argon plasma coagulation is first-line and radiofrequency ablation is second-line treatment for chronic bleeding secondary to gastric antral vascular ectasia. There are a variety of endoscopic treatment modalities for cirrhosis-related gastrointestinal bleeding, and the appropriate therapy depends on the location of the bleed, history or presence of acute bleeding, and risk factors for intervention-related adverse events.
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Rimševičius L, Galkauskas D, Lavinskas J, Šestelinska E, Mačionienė E, Laučytė-Cibulskienė A, Rėkutė S, Miglinas M. Gastric antral vascular ectasia should not be overlooked in erythropoietin resistance: a series of case reports. Acta Med Litu 2018; 25:219-225. [PMID: 31308827 DOI: 10.6001/actamedica.v25i4.3932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Gastric antral vascular ectasia (GAVE) is currently recognized as an important cause of upper gastrointestinal (GI) haemorrhage, being responsible for about 4% of non-variceal upper GI haemorrhages and typically presents in middle-aged females. GAVE, also called "watermelon stomach", is diagnosed through esophagogastroduodenoscopy and is characterized by the presence of visible columns of red tortuous enlarged vessels along the longitudinal folds of the antrum. The pathogenesis is still obscure and many hypotheses have been proposed such as mechanical stress, humoral and autoimmune factors. In the last two decades, numerous therapeutic strategies have been proposed, including surgical, endoscopic, and medical choices, yet successful treatment of GAVE continues to be a challenge. Currently, given the rapid response, safety, and efficacy, endoscopic ablative modalities have largely usurped medical treatments as first-line therapy, particularly using argon plasma coagulation. The actual GAVE prevalence in patients with end-stage renal disease (ESRD) is not clear, yet in difficult cases it should be considered as a cause of erythropoietin resistance. Case presentation We report four clinical cases of GAVE syndrome patients diagnosed with stage 4 to 5 chronic kidney disease. All patients presented with anaemia and GI haemorrhage, the origin of which turned out to be GAVE syndrome. Conclusions GAVE syndrome is a serious condition in ESRD patients, especially in those presenting with treatment-refractory anaemia. Realization of its aetiology and characteristics is essential to suspect, diagnose, and treat gastric ectasia. Only proper diagnosis and well-timed disease treatment can significantly improve a patient's medical condition and future prognosis.
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Affiliation(s)
| | | | | | | | | | | | - Skirmantė Rėkutė
- Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Marius Miglinas
- Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
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Navaneethan U, Thosani N, Goodman A, Manfredi M, Pannala R, Parsi MA, Smith ZL, Sullivan SA, Banerjee S, Maple JT. Radiofrequency ablation devices. VideoGIE 2017; 2:252-259. [PMID: 29905337 PMCID: PMC5992954 DOI: 10.1016/j.vgie.2017.06.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Key Words
- APC, argon plasma coagulation
- ASGE, American Society for Gastrointestinal Endoscopy
- BE, Barrett's esophagus
- CCA, cholangiocarcinoma
- CE-D, complete eradication of dysplasia
- CE-IM, complete eradication of intestinal metaplasia
- CI, confidence interval
- CPT, current procedural technology
- ESD, endoscopic submucosal dissection
- GAVE, gastric antral vascular ectasia
- HGD, high-grade dyplasia
- IMC, intramucosal carcinoma
- LGD, low-grade dysplasia
- NET, neuroendocrine tumors
- PDT, photodynamic therapy
- RF, radiofrequency
- RFA, radiofrequency ablation
- RP, radiation proctopathy
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Maida M, Camilleri S, Manganaro M, Garufi S, Scarpulla G. Radiofrequency Ablation for Treatment of Refractory Gastric Antral Vascular Ectasia: A Systematic Review of the Literature. Gastroenterol Res Pract. 2017;2017:5609647. [PMID: 28835751 PMCID: PMC5556612 DOI: 10.1155/2017/5609647] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/17/2017] [Accepted: 06/28/2017] [Indexed: 01/10/2023] Open
Abstract
Background and Study Aims GAVE is an uncommon cause of upper nonvariceal bleeding and often manifests itself as occult bleeding with chronic anemia. To date, the standard of care for GAVE is endoscopic treatment with thermoablative techniques. Despite good technical results, approximately two thirds of patients remain dependent on transfusions after the therapy. One of the emerging and more promising endoscopic treatments for GAVE is radiofrequency ablation (RFA). The aim of this study is to perform a systematic review of literature in order to assess current evidence supporting the effectiveness of this technique for treatment of refractory GAVE. Materials and Methods Through electronic search, we identified 14 records, and after removal of duplicates and irrelevant studies, we selected 10 studies on radiofrequency ablation of GAVE: 4 prospective open-label single-center studies, 1 retrospective multicentric study, and 5 case reports. Results Among all 72 treated patients reported in literature, 74.3% achieved a clinical response, while nonfatal AEs have been reported in 4.2% of cases. Conclusions Despite some qualitative limitations, all literature data support effectiveness of RFA for treatment of refractory GAVE. In the future, large prospective controlled trials with adequate follow-up are needed to better assess the effectiveness and safety of this procedure.
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Patel A, Patel S, Wickremesinghe PC, Vadada D. Radiofrequency ablation using Barrx ® for the endoscopic treatment of gastric antral vascular ectasia: a series of three cases and a review of the literature on treatment options. Clin Exp Gastroenterol 2017; 10:113-120. [PMID: 28744150 PMCID: PMC5513699 DOI: 10.2147/ceg.s80241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Gastric antral vascular ectasia (GAVE), also known as “watermelon stomach”, is an uncommon condition, which can cause gastrointestinal bleeding due to rupture of blood vessels that line the stomach. The pathogenesis of GAVE remains unclear; however it is thought that hemodynamic changes, mechanical stress, and autoimmune factors all have a part to play. A range of conditions are also commonly associated with the syndrome, such as portal hypertensive gastropathy, liver cirrhosis, and autoimmune disorders. Less commonly, chronic renal failure, cardiac diseases, and bone marrow transplantation have coexisted with GAVE. The diagnosis is usually based on visualization of the tissue upon endoscopy; however, histology plays a role in uncertain cases. The typical “watermelon” appearance relates to the tissue having a striped appearance radiating out from the pylorus. Medical treatment has failed to show satisfactory results and surgery is usually considered as a last resort, due to its increased risk for complications and mortality. Lasers and argon plasma coagulation have been used recently, and been shown to be as effective as surgery and a safer option. We present three cases of gastric antral vascular ectasia treated at our institution with radiofrequency ablation and review the literature on treatment modalities for GAVE.
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Affiliation(s)
- Anish Patel
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Sunil Patel
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | | | - Deepak Vadada
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
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Smith E, Tekola B, Patrie J, Cornella S, Caldwell S. Clinical Characterization of Gastric Antral Vascular Ectasia: A Potential Manifestation of the Metabolic Syndrome. Am J Med 2016; 129:1329.e19-1329.e23. [PMID: 27476085 DOI: 10.1016/j.amjmed.2016.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 07/05/2016] [Accepted: 07/05/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Gastric antral vascular ectasia is a relatively common endoscopic finding. Past studies have shown an association of gastric antral vascular ectasia with cirrhosis and autoimmune disorders. We aimed to re-examine these associations and to investigate a possible association of gastric antral vascular ectasia with features of the metabolic syndrome. METHODS There were 135 patients with a diagnosis of gastric antral vascular ectasia from years 1995-2013 seen at the University of Virginia who were identified from a clinical data repository and age and sex matched to a cohort of patients without gastric antral vascular ectasia undergoing endoscopy within the same time frame as the index cases. The groups were compared for comorbidities including autoimmune disease, cirrhosis, vascular disease, body mass index (BMI), diabetes mellitus, and cirrhosis due to nonalcoholic steatohepatitis. RESULTS Sixty-four percent of gastric antral vascular ectasia patients were cirrhotic, compared with 14% of controls (P <.001). Vascular disease was more common in the gastric antral vascular ectasia cohort (57% vs 36%; P <.001). The mean BMI was also higher in the gastric antral vascular ectasia cohort (33.7 kg/m2 vs 28.8 kg/m2; P <.001). Diabetes mellitus and nonalcoholic steatohepatitis cirrhosis were more frequently observed in gastric antral vascular ectasia subjects (64% vs 29% in controls [P <.001] and 28% vs 2% [P <.001], respectively). There was not an increased prevalence of autoimmune disease in gastric antral vascular ectasia patients vs controls (15% vs 13%; P = .861). CONCLUSION These results confirm the association of gastric antral vascular ectasia with underlying cirrhosis and revealed a significant correlation of gastric antral vascular ectasia with features of metabolic syndrome such as diabetes, BMI, vascular disease, and nonalcoholic steatohepatitis cirrhosis. The pathophysiology of gastric antral vascular ectasia remains uncertain, but we speculate that it may be a manifestation of the metabolic syndrome.
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Affiliation(s)
- Elliot Smith
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville
| | - Bezawit Tekola
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville
| | - James Patrie
- Division of Public Health, University of Virginia, Charlottesville
| | - Scott Cornella
- Division of Internal Medicine, University of Virginia, Charlottesville
| | - Stephen Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville.
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Qiu H, Mao Y, Zeng J, Wang Y, Zhang J, Huang N, Liu Q, Yang Y, Linghu E, Gu Y. Vascular-targeted photodynamic therapy of gastric antral vascular ectasia (GAVE). J Photochem Photobiol B 2016; 166:58-62. [PMID: 27871022 DOI: 10.1016/j.jphotobiol.2016.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 10/25/2016] [Accepted: 10/27/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND STUDY AIM Vascular-targeted photodynamic therapy (V-PDT) has been used for several benign vascular diseases. The aim of this pilot study was to demonstrate the potential benefits of VPDT in the treatment of gastric antral vascular ectasia (GAVE). PATIENTS AND METHODS Data from patients with GAVE (n=5) who underwent endoscopic V-PDT were analyzed retrospectively. Pre- and post-V-PDT clinical and endoscopic features, hemoglobin levels, and transfusion requirement were compared. RESULTS The five GAVE patients received one to four sessions of V-PDT. The hemoglobin levels of all five patients increased steadily following V-PDT. Within 6-48months of follow-up, gastrointestinal bleeding and melena disappeared in all five patients and none of the patients needed a transfusion. Endoscopy examinations showed that the dilated vessels had disappeared without scar formation. No significant side effects or adverse reactions were reported. CONCLUSION This preliminary study indicates the good selectivity, safety, and efficacy of V-PDT in the treatment of patients with GAVE. Larger prospective studies are needed to further confirm the feasibility of using V-PDT to treat patients with GAVE.
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Affiliation(s)
- Haixia Qiu
- Department of Laser Medicine, Chinese PLA General Hospital, China
| | - Yongping Mao
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, China.
| | - Jing Zeng
- Department of Laser Medicine, Chinese PLA General Hospital, China
| | - Ying Wang
- Department of Laser Medicine, Chinese PLA General Hospital, China
| | - Jiaying Zhang
- Department of Laser Medicine, Chinese PLA General Hospital, China
| | - Naiyang Huang
- Department of Laser Medicine, Chinese PLA General Hospital, China
| | - Qingsen Liu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, China
| | - Yunsheng Yang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, China
| | - Enqiang Linghu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, China
| | - Ying Gu
- Department of Laser Medicine, Chinese PLA General Hospital, China.
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Mendonca EQ, de Oliveira JF, Maluf-Filho F. Argon plasma coagulation and radiofrequency ablation in nonvariceal upper gastrointestinal bleeding. Techniques in Gastrointestinal Endoscopy 2016. [DOI: 10.1016/j.tgie.2016.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
Systemic sclerosis is a multisystem autoimmune disorder that involves the gastrointestinal tract in more than 90% of patients. This involvement can extend from the mouth to the anus, with the oesophagus and anorectum most frequently affected. Gut complications result in a plethora of presentations that impair oral intake and faecal continence and, consequently, have an adverse effect on patient quality of life, resulting in referral to gastroenterologists. The cornerstones of gastrointestinal symptom management are to optimize symptom relief and monitor for complications, in particular anaemia and malabsorption. Early intervention in patients who develop these complications is critical to minimize disease progression and improve prognosis. In the future, enhanced therapeutic strategies should be developed, based on an ever-improving understanding of the intestinal pathophysiology of systemic sclerosis. This Review describes the most commonly occurring clinical scenarios of gastrointestinal involvement in patients with systemic sclerosis as they present to the gastroenterologist, with recommendations for the suggested assessment protocol and therapy in each situation.
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Affiliation(s)
- Anton Emmanuel
- Gastrointestinal Physiology Unit, University College Hospital, 235 Euston Road, London NW1 2BU, UK
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22
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Elhendawy M, Mosaad S, Alkhalawany W, Abo-Ali L, Enaba M, Elsaka A, Elfert AA. Randomized controlled study of endoscopic band ligation and argon plasma coagulation in the treatment of gastric antral and fundal vascular ectasia. United European Gastroenterol J 2015; 4:423-8. [PMID: 27403309 DOI: 10.1177/2050640615619837] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 11/02/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Gastric antral vascular ectasia (GAVE) is characterized by mucosal and submucosal vascular ectasia causing recurrent hemorrhage and thus, chronic anemia, in patients with cirrhosis. Treatment with argon plasma coagulation (APC) is an effective and safe method, but requires multiple sessions of endoscopic therapy. Endoscopic band ligation (EBL) was found to be a good alternative for APC as a treatment for GAVE, especially in refractory cases. The aim of this prospective randomized controlled study was to evaluate the safety and efficacy of EBL, as compared to APC, in the treatment of GAVE and gastric fundal vascular ectasia (GFVE). PATIENTS AND METHODS A total of 88 cirrhotic patients with GAVE were prospectively randomized to endoscopic treatment with either EBL or APC, every 2 weeks until complete obliteration was accomplished; then they were followed up endoscopically after 6 months, plus they had monthly measurement of hemoglobin levels during that period. RESULTS We describe the presence of mucosal and submucosal lesions in the gastric fundal area that were similar to those found in GAVE in 13 patients (29.5%) of the EBL group and 9 patients (20.5%) of the APC group; we named this GFVE. In these cases, we treated the fundal lesions with the same techniques we had used for treating GAVE, according to the randomization. We found that EBL significantly decreased the number of sessions required for complete obliteration of the lesions (2.98 sessions compared to 3.48 sessions in the APC group (p < 0.05)). Hemoglobin levels increased significantly after obliteration of the lesions in both groups, compared to pretreatment values (p < 0.05), but with no significant difference between the two groups (p > 0.05); however, the EBL group of patients required a significantly smaller number of units of blood transfusion than the APC group of patients (p < 0.05). There were no significant differences in adverse events nor complications between the two groups (p > 0.05). CONCLUSIONS This study described and histologically proved the presence of GFVE occurring comcomitantly with GAVE in cirrhotic patients. We showed that GFVE can be successfully managed by EBL or APC. Our study revealed that EBL is more effective and is comparable in safety to APC, in the treatment of GAVE and GFVE in cirrhotic patients.
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Affiliation(s)
| | - Samah Mosaad
- Department of Tropical Medicine, Tanta University Hospital, Egypt
| | | | - Lobna Abo-Ali
- Department of Tropical Medicine, Tanta University Hospital, Egypt
| | - Mohamed Enaba
- Department of Internal Medicine, Tanta University Hospital, Egypt
| | - Aymen Elsaka
- Department of Pathology, Tanta University Hospital, Egypt
| | - Asem A Elfert
- Department of Tropical Medicine, Tanta University Hospital, Egypt
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Szura M, Pasternak A. Upper non-variceal gastrointestinal bleeding - review the effectiveness of endoscopic hemostasis methods. World J Gastrointest Endosc 2015; 7:1088-1095. [PMID: 26421105 PMCID: PMC4580950 DOI: 10.4253/wjge.v7.i13.1088] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 06/17/2015] [Accepted: 09/07/2015] [Indexed: 02/05/2023] Open
Abstract
Upper non-variceal gastrointestinal bleeding is a condition that requires immediate medical intervention and has a high associated mortality rate (exceeding 10%). The vast majority of upper gastrointestinal bleeding cases are due to peptic ulcers. Helicobacter pylori infection, non-steroidal anti-inflammatory drugs and aspirin are the main risk factors for peptic ulcer disease. Endoscopic therapy has generally been recommended as the first-line treatment for upper gastrointestinal bleeding as it has been shown to reduce recurrent bleeding, the need for surgery and mortality. Early endoscopy (within 24 h of hospital admission) has a greater impact than delayed endoscopy on the length of hospital stay and requirement for blood transfusion. This paper aims to review and compare the efficacy of the types of endoscopic hemostasis most commonly used to control non-variceal gastrointestinal bleeding by pooling data from the literature.
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24
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Garg H, Gupta S, Anand AC, Broor SL. Portal hypertensive gastropathy and gastric antral vascular ectasia. Indian J Gastroenterol 2015; 34:351-8. [PMID: 26564121 DOI: 10.1007/s12664-015-0605-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 10/17/2015] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Hitendra Garg
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India.
| | - Subhash Gupta
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India
| | - A C Anand
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India
| | - S L Broor
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India.,Gastroenterology and Hepatology, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India
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Abstract
PURPOSE OF REVIEW Acute, nonvariceal upper gastrointestinal bleeding (UGIB) is a common medical emergency encountered worldwide. Despite medical and technological advances, it remains associated with significant morbidity and mortality. RECENT FINDINGS Rapid patient assessment and management are paramount. When indicated, upper endoscopy in patients presenting with acute UGIB is effective for both diagnosis of the bleeding site and provision of endoscopic hemostasis. Endoscopic hemostasis significantly reduces rebleeding rates, blood transfusion requirements, length of hospital stay, surgery, and mortality. Furthermore, early upper endoscopy, defined as being performed within 24 h of patient presentation, improves patient outcomes. SUMMARY A structured approach to the patient with acute UGIB that includes early hemodynamic resuscitation and stabilization, preendoscopic risk stratification using validated instruments, pharmacologic and endoscopic intervention, and postendoscopy therapy is important to optimize patient outcome and assure efficient use of medical resources.
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Becq A, Camus M, Rahmi G, de Parades V, Marteau P, Dray X. Emerging indications of endoscopic radiofrequency ablation. United European Gastroenterol J 2015; 3:313-24. [PMID: 26279839 DOI: 10.1177/2050640615571159] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 01/12/2015] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Radiofrequency ablation (RFA) is a well-validated treatment of dysplastic Barrett's esophagus. Other indications of endoscopic RFA are under evaluation. RESULTS Four prospective studies (total 69 patients) have shown that RFA achieved complete remission of early esophageal squamous intra-epithelial neoplasia at a rate of 80%, but with a substantial risk of stricture. In the setting of gastric antral vascular ectasia, two prospective monocenter studies, and a retrospective multicenter study, (total 51 patients), suggest that RFA is efficacious in terms of reducing transfusion dependency. In the setting of chronic hemorrhagic radiation proctopathy, a prospective monocenter study and a retrospective multicenter study (total 56 patients) suggest that RFA is an efficient treatment. A retrospective comparative study (64 patients) suggests that RFA improves stents patency in malignant biliary strictures. CONCLUSIONS Endoscopic RFA is an upcoming treatment modality in early esophageal squamous intra-epithelial neoplasia, as well as in gastric, rectal, and biliary diseases.
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Affiliation(s)
- Aymeric Becq
- Department of Gastroenterology and Hepatology, Sorbonne Paris Cité Paris 7 University & APHP Lariboisière Hospital, Paris, France
| | - Marine Camus
- Department of Gastroenterology and Hepatology, Sorbonne Paris Cité Paris 7 University & APHP Lariboisière Hospital, Paris, France
| | - Gabriel Rahmi
- Department of Gastroenterology and Hepatology, Sorbonne Paris Cité Paris 5 University & APHP, European Georges Pompidou Hospital, Paris, France
| | - Vincent de Parades
- Department of Medicosurgical Proctology, Léopold Bellan Institute, Saint Joseph Hospital, Paris, France
| | - Philippe Marteau
- Department of Gastroenterology and Hepatology, Sorbonne Paris Cité Paris 7 University & APHP Lariboisière Hospital, Paris, France
| | - Xavier Dray
- Department of Gastroenterology and Hepatology, Sorbonne Paris Cité Paris 7 University & APHP Lariboisière Hospital, Paris, France
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Abstract
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.
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Montagnac R, Blaison D, Brahimi S, Schendel A, Levasseur T, Takin R. [Watermelon stomach: Chronic renal failure and/or imatinib?]. Nephrol Ther 2015; 11:496-501. [PMID: 26165799 DOI: 10.1016/j.nephro.2015.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/13/2015] [Indexed: 02/07/2023]
Abstract
Watermelon stomach or gastric antral vascular ectasia (GAVE) syndrome is an uncommon cause of sometimes severe upper gastro-intestinal bleeding. Essentially based on a pathognomonic endoscopic appearance, its diagnosis may be unrecognised because mistaken with portal hypertensive gastropathy, while treatment of these two entities is different. Its etiopathogeny remains still unclear, even if it is frequently associated with different systemic illnesses as hepatic cirrhosis, autoimmune disorders and chronic renal failure. The mechanism inducing these vascular ectasia may be linked with mechanical stress on submucosal vessels due to antropyloric peristaltic motility dysfunction modulated by neurohormonal vasoactive alterations. Because medical therapies are not very satisfactory, among the endoscopic modalities, argon plasma coagulation seems to be actually the first-line treatment because the most effective and safe. However, surgical antrectomy may be sometimes necessary. Recently GAVE syndrome appeared as a new adverse reaction of imatinib mesylate, one of the tyrosine kinase inhibitors used in chronic myeloid leukemia, and we report here the observation of such a pathology in one patient treated at the same time by haemodialysis and by imatinib mesylate for chronic myeloid leukemia.
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Jana T, Thosani N, Fallon MB, Dupont AW, Ertan A. Radiofrequency ablation for treatment of refractory gastric antral vascular ectasia (with video). Endosc Int Open 2015; 3:E125-7. [PMID: 26135652 PMCID: PMC4477020 DOI: 10.1055/s-0034-1391323] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/21/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Gastric antral vascular ectasia (GAVE) is a known cause of gastrointestinal bleeding and chronic iron deficiency anemia. Endoscopic therapy with argon plasma coagulation (APC) is widely used for treatment of GAVE, but most patients continue to require repeated blood transfusions and multiple endoscopic procedures (refractory GAVE). We describe our initial experience regarding safety and efficacy of radiofrequency ablation (RFA) therapy in treating patients with refractory GAVE. PATIENTS AND METHODS We prospectively enrolled seven patients with refractory GAVE who had multiple prior treatments with APC. These patients were treated with RFA (HALO90 ULTRA Ablation Catheter System; Covidien, GI Solutions, Sunnyvale, CA) at Ertan Digestive Disease Center at our tertiary University Hospital. RESULTS Seven patients underwent a total of 12 RFA procedures for treatment of refractory GAVE. The median number of RFA procedures was 2 (Range, 1 - 3). Average pre- and post-procedural hemoglobin were 9.3 g/dL and 10.16 g/dL, respectively. Five of seven patients (71 %) were transfusion-free after the RFA treatments while two patients continued to require blood transfusions. There were no complications in this series. CONCLUSION RFA can be an effective alternative to APC for treatment of GAVE refractory to previous endoscopic therapy. Additional studies are needed to identify which subset of patients will benefit the most with RFA treatment.
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Affiliation(s)
- Tanima Jana
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, United States
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, United States,Division of Gastroenterology & Hepatology, Stanford University School of Medicine, Stanford, California, United States
| | - Michael B. Fallon
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, United States,Ertan Digestive Disease Center, Memorial Hermann Hospital, Houston, Texas, United States
| | - Andrew W. Dupont
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, United States,Ertan Digestive Disease Center, Memorial Hermann Hospital, Houston, Texas, United States
| | - Atilla Ertan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, United States,Ertan Digestive Disease Center, Memorial Hermann Hospital, Houston, Texas, United States
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Casas M, Calvet X, Vergara M, Bella MR, Junquera F, Martinez-bauer E, Campo R. Lesiones vasculares gástricas en la cirrosis: gastropatía y ectasia vascular antral. Gastroenterología y Hepatología 2015; 38:97-107. [DOI: 10.1016/j.gastrohep.2014.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/12/2014] [Accepted: 10/27/2014] [Indexed: 02/08/2023]
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Abstract
Gastrointestinal tract (GIT) commonly affects patients with systemic sclerosis (SSc). The GI involvement is quite heterogeneous varying from asymptomatic disease to significant dysmotility causing complications like malabsorption, weight loss and severe malnutrition. This review focuses on the management of GI involvement in SSc and has been categorized based on the segment of GIT involved. A brief discussion on the role of patient reported outcome measures in SSc-GI involvement has also been incorporated.
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Affiliation(s)
- Vivek Nagaraja
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | | | - Terri Getzug
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan
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32
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Abstract
The introduction of targeted agents has improved survival for patients with a number of types of cancer, including several breast cancer subtypes. However, these agents are not without toxicities, and the fact that many patients are now on targeted therapy for extended periods of time has presented new challenges for the management of adverse effects. Everolimus is an inhibitor of mtor (the mammalian target of rapamycin) that is used as targeted therapy for advanced, hormone receptor-positive, her2-negative breast cancer in postmenopausal women in combination with exemestane, after treatment failure with letrozole or anastrozole. Minor hemorrhagic events are relatively common with targeted agents, but life-threatening hemorrhages, although uncommon, can also occur. We report a case of life-threatening gastrointestinal bleeding in a 48-year-old woman being treated with everolimus for advanced infiltrating ductal carcinoma of the breast. The bleeding was successfully treated with 13 sessions of endoscopic hemostasis using argon plasma coagulation.
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Affiliation(s)
- H Assi
- Division of Medical Oncology/Hematology, The Moncton Hospital, Moncton, NB. ; Department of Medicine, Dalhousie University, Halifax, NS
| | - N Abdel-Samad
- Division of Medical Oncology/Hematology, The Moncton Hospital, Moncton, NB. ; Department of Medicine, Memorial University, St. John's, NL
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Pineda Oliva OJ, Valencia Romero A, Soto JC, Diaz Oyola M, Valdivia Balbuena M, Chuc Baeza G, Cuevas Osorio V, Farell Rivas J. Ectasia vascular gástrica antral: reporte de un caso. Endoscopia 2014. [DOI: 10.1016/j.endomx.2014.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
A major cause of cirrhosis related morbidity and mortality is the development of variceal bleeding, a direct consequence of portal hypertension. Less common causes of gastrointestinal bleeding are peptic ulcers, malignancy, angiodysplasia, etc. Upper gastrointestinal bleeding has been classified according to the presence of a variceal or non-variceal bleeding. Although non-variceal gastrointestinal bleeding is not common in cirrhotic patients, gastroduodenal ulcers may develop as often as non-cirrhotic patients. Ulcers in cirrhotic patients may be more severe and less frequently associated with chronic intake of non-steroidal anti-inflammatory drugs, and may require more frequently endoscopic treatment. Portal hypertensive gastropathy (PHG) refers to changes in the mucosa of the stomach in patients with portal hypertension. Patients with portal hypertension may experience bleeding from the stomach, and pharmacologic or radiologic interventional procedure may be useful in preventing re-bleeding from PHG. Gastric antral vascular ectasia (GAVE) seems to be different disease entity from PHG, and endoscopic ablation can be the first-line treatment.
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Affiliation(s)
- Woo Jin Chung
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
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Keohane J, Berro W, Harewood GC, Murray FE, Patchett SE. Band ligation of gastric antral vascular ectasia is a safe and effective endoscopic treatment. Dig Endosc 2013; 25:392-6. [PMID: 23808945 DOI: 10.1111/j.1443-1661.2012.01410.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 09/28/2012] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- John Keohane
- Department of Gastroenterology and Hepatology, Beaumont Hospital, Dublin, Ireland.
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36
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Abstract
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.
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Affiliation(s)
- Papia Kar
- Department of Internal Medicine, Marshfield Clinic, Marshfield, Wisconsin USA
| | - Subhashis Mitra
- Department of Internal Medicine, Marshfield Clinic, Marshfield, Wisconsin USA
| | | | - Camille F. Torbey
- Department of Gastroenterology, Marshfield Clinic, Marshfield, Wisconsin USA
- Corresponding Author: Camille F. Torbey, MD, FACP, AGAF, Department of Gastroenterology, 1000 North Oak Avenue, Marshfield, WI 54449, Tel: 715-221-7833, Fax: 715-387-5663,
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Yoshida H, Takahashi H, Akoshima H, Chida N, Noguchi K, Tanabe N, Mano Y, Ukai K, Tadokoro K. Successful treatment of refractory gastric antral vascular ectasia using transcatheter arterial embolization. Clin J Gastroenterol 2013; 6:231-6. [DOI: 10.1007/s12328-013-0385-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 04/30/2013] [Indexed: 12/11/2022]
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Abstract
Gastric antral vascular ectasia (GAVE), also called watermelon stomach, is a rare cause of gastrointestinal (GI) bleeding. GAVE is associated with a number of conditions, including portal hypertension, chronic kidney disease (CKD), and collagen vascular diseases, especially scleroderma. Limited reports of GAVE are present in CKD patients. Argon plasma coagulation (APC) is an effective therapy for GAVE. We describe the case of a CKD, stage V patient, who presented with recurrent blood loss in stools and transfusion-dependent anemia. Her endoscopy revealed GAVE, which was managed uneventfully with APC.
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Affiliation(s)
- S Lata
- Department of Nephrology, Institute of Liver and Biliary Sciences, New Delhi, India
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Hirayama M, Azuma E, Nakazawa A, Iwamoto S, Toyoda H, Komada Y. Simultaneous occurrence of gastric antral vascular ectasia and protein-losing enteropathy in chronic graft-versus-host disease. Int J Hematol 2013; 97:529-34. [DOI: 10.1007/s12185-013-1279-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 01/16/2013] [Accepted: 01/20/2013] [Indexed: 12/22/2022]
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40
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Bon C, Aparicio T, Vincent M, Mavros M, Bejou B, Raynaud JJ, Zampeli E, Airinei G, Sautereau D, Benamouzig R, Michopoulos S. Long-acting somatostatin analogues decrease blood transfusion requirements in patients with refractory gastrointestinal bleeding associated with angiodysplasia. Aliment Pharmacol Ther 2012; 36:587-93. [PMID: 22831465 DOI: 10.1111/apt.12000] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 04/27/2012] [Accepted: 07/10/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastrointestinal angiodysplasias (GIADs) may be the cause of recurrent bleeding, despite endoscopic treatment. AIM To evaluate the effect of long-acting somatostatin analogues on blood transfusion requirements, in patients with refractory bleeding due to GIADs. METHODS Consecutive patients with recurrent bleeding from GIADs were enrolled. They received somatostatin analogue treatment for at least 6 months. The efficacy was evaluated in terms of blood transfusions, frequency of bleeding episodes and haemoglobin level during 6 months of treatment (Period During) compared to a 6-months' period before treatment (Period Before). RESULTS Fifteen patients were enrolled from 2007 to 2010. The median duration of somatostatin analogue treatment was 12 months (range: 6-36). The number of transfusions significantly decreased in Period During compared with Period Before [median number: 2 (0-14) vs. 10 (6-24); P < 0.001]. The percentage of patients who experienced a bleeding event was lower during somatostatin analogues treatment (20% vs. 73%; P = 0.01). The mean haemoglobin level was significantly higher when somatostatin analogues were offered [median: 10 g/dL (9-13) vs. 7 (5-8.5); P < 0.001]. None of the patients discontinued treatment due to side effects. CONCLUSIONS Long-acting somatostatin analogues treatment decreased transfusion needs in patients with refractory bleeding from gastrointestinal angiodysplasias. Bleeding episodes were limited and haemoglobin improved during treatment. Long-acting somatostatin analogues may represent an option for the management of patients with chronic bleeding due to gastrointestinal angiodysplasias.
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Affiliation(s)
- C Bon
- Department of Gastroenterology, Avicenne Hospital, APHP, Bobigny, France
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41
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Chiu YC, Lu LS, Wu KL, Tam W, Hu ML, Tai WC, Chiu KW, Chuah SK. Comparison of argon plasma coagulation in management of upper gastrointestinal angiodysplasia and gastric antral vascular ectasia hemorrhage. BMC Gastroenterol 2012; 12:67. [PMID: 22681987 PMCID: PMC3439282 DOI: 10.1186/1471-230x-12-67] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 06/09/2012] [Indexed: 01/10/2023] Open
Abstract
Background Vascular ectasias, including gastric antral vascular ectasia (GAVE) and angiodysplasia, are increasingly recognized as important sources of gastrointestinal bleeding. This study investigated and compared the efficacies and outcomes of treatment of upper gastrointestinal (UGI) angiodysplasia and GAVE hemorrhage by endoscopic argon plasma coagulation (APC). Methods From January 2006 to December 2009, 46 patients diagnosed with upper GI bleeding caused by angiodysplasia or GAVE at a tertiary hospital were recruited into this study. They included 26 males and 20 females with an average age of 65.6 years (range, 45–90 years). All patients underwent APC for hemostasis during an endoscopic procedure. Parameters such as underlying co-morbidities, number of endoscopic treatment sessions, recurrent bleeding, and clinical outcomes during follow-up were analyzed. Results The 46 patients with UGI vascular ectasia hemorrhage included 27 patients with angiodysplasia and 19 with GAVE. The patients with angiodysplasia were older than those with GAVE (71.6 ± 10.2 years versus 61.8 ± 11.9 years, P = 0.005). More GAVE patients than angiodysplasia patients had co-existing liver cirrhosis (63.2% versus 25.9%, P = 0.012). The patients with GAVE had a higher rate of recurrent bleeding (78.9% versus 7.4%, P < 0.001) and required more treatment sessions to achieve complete hemostasis (2.4 ± 1.4 versus 1.1 ± 0.1, P < 0.001) than those with angiodysplasia. Univariate analysis demonstrated that age greater than 60 years (odds ratio (OR) = 8.929, P = 0.003), GAVE (OR = 0.021, P < 0.001), and previous radiation therapy (OR = 11.667, P = 0.032) were associated with higher rates of recurrent bleeding. Further multivariate analysis revealed that GAVE was the only independent risk factor for recurrent bleeding after APC treatment (OR = 0.027, P < 0.001). Conclusion Endoscopic hemostasis with APC is a safe treatment modality for both angiodysplasia and vascular ectasia bleeding. The efficacy of APC treatment is greater for angiodysplasia than for vascular ectasia bleeding. GAVE patients have a higher recurrent bleeding rate and may require multiple treatment sessions for sustained hemostasis.
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Affiliation(s)
- Yi-Chun Chiu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung City 833, Taiwan
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42
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Hwang JH, Fisher DA, Ben-Menachem T, Chandrasekhara V, Chathadi K, Decker GA, Early DS, Evans JA, Fanelli RD, Foley K, Fukami N, Jain R, Jue TL, Khan KM, Lightdale J, Malpas PM, Maple JT, Pasha S, Saltzman J, Sharaf R, Shergill AK, Dominitz JA, Cash BD. The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest Endosc 2012; 75:1132-8. [PMID: 22624808 DOI: 10.1016/j.gie.2012.02.033] [Citation(s) in RCA: 197] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 02/20/2012] [Indexed: 02/08/2023]
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43
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Saad Aldin E, Mourad F, Tfayli A. Gastric antral vascular ectasia in a patient with GIST after treatment with imatinib: case report and literature review. Jpn J Clin Oncol 2012; 42:447-50. [PMID: 22422898 DOI: 10.1093/jjco/hys032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Imatinib mesylate is a receptor kinase inhibitor approved by the Food and Drug Administration for the treatment of malignant metastatic and/or unresectable gastrointestinal stromal tumors and chronic myelogenous leukemia. Although imatinib is generally well tolerated, certain adverse drug reactions are common. These include gastrointestinal side-effects such as diarrhea, nausea and vomiting, as well as hematological side-effects and other miscellaneous side-effects such as fatigue, edema, dermatitis and dyspnea. We present a previously unreported adverse effect of imatinib, gastric antral vascular ectasia, in a 74-year-old woman with gastrointestinal stromal tumor in remission treated with adjuvant imatinib. Endoscopy performed prior to starting imatinib showed normal gastric mucosa, but 8 months after starting imatinib showed diffuse gastric inflammation. Repeat endoscopy 1 month after discontinuing imatinib showed significant improvement in gastric inflammation.
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Affiliation(s)
- Ehab Saad Aldin
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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44
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Krystallis C, Masterton GS, Hayes PC, Plevris JN. Update of endoscopy in liver disease: More than just treating varices. World J Gastroenterol 2012; 18:401-11. [PMID: 22346246 PMCID: PMC3272639 DOI: 10.3748/wjg.v18.i5.401] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 06/02/2011] [Accepted: 06/09/2011] [Indexed: 02/06/2023] Open
Abstract
The management of complications in liver disease is often complex and challenging. Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease. In this review, relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension. The main areas covered are safety of endoscopy in patients with liver disease, the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound, esophageal capsule, argon plasma coagulation, spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology. It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices. As the technology in endoscopy expands, so does the role of the endoscopist in liver disease.
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45
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Abstract
Watermelon stomach is the description usually given to the endoscopic appearance of gastric antral vascular ectasia. The classical histopathological features of gastric antral vascular ectasia include; hyperplasia of the surface epithelium and the fibromuscular layer of the lamina propria associated with the presence of dilated submucosal venous channels and thrombosed capillaries. This condition can be associated with liver cirrhosis, chronic renal failure and autoimmune disorders. Herein, we report the watermelon endoscopic appearance of the gastric mucosa in a 12-year-old Saudi girl with erosive gastritis.
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Affiliation(s)
- Omar I Saadah
- Department of Pediatrics, King Abdul-Aziz University, Jeddah, Saudi Arabia.
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46
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Montero A, Fernández-Lizarbe E, Rodríguez MÁ, Hernanz R, Polo A, Ramos A. External-beam radiotherapy: A realistic therapeutic option for the gastric antral vascular ectasia. Rep Pract Oncol Radiother 2012; 17:233-6. [PMID: 24377029 DOI: 10.1016/j.rpor.2012.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 01/16/2012] [Accepted: 03/10/2012] [Indexed: 11/29/2022] Open
Abstract
The gastric antral vascular ectasia (GAVE) is a well recognizable endoscopic entity characterized by the presence of multiple linear angioectatic vessels predominantly located in the antrum, with a typical appearance of "watermelon stomach". This condition typically affects elderly females presenting as iron-deficiency anaemia due to chronic gastric bleeding. Standard treatment is endoscopic ablation of the gastric mucosa. For non-responders, radical surgery is considered a curative treatment but with considerable morbidity and mortality. Radiation therapy is a well-known alternative for many benign diseases, including anomalous vascular hyperproliferative diseases, although its role has not been defined for GAVE. The present case illustrates the efficacy and tolerance of radiotherapy in the treatment of symptomatic gastric watermelon.
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Affiliation(s)
- Angel Montero
- Radiation Oncology Department, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | | | | | - Raúl Hernanz
- Radiation Oncology Department, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | - Alfredo Polo
- Radiation Oncology Department, Universitary Hospital Ramón y Cajal, Madrid, Spain
| | - Alfredo Ramos
- Radiation Oncology Department, Universitary Hospital Ramón y Cajal, Madrid, Spain
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47
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Singh YP, Prasad BNS, Agarwal V. Unusual cause of anaemia in scleroderma: Gastric antral vascular ectasia. Indian Journal of Rheumatology 2011. [DOI: 10.1016/s0973-3698(11)60086-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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48
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Briggs TA, Hubbard M, Hawkins C, Cole T, Livingston JH, Crow YJ, Pigott A. Treatment of Gastrointestinal Bleeding in a Probable Case of Cerebroretinal Microangiopathy with Calcifications and Cysts. Mol Syndromol 2010; 1:159-162. [PMID: 21373254 DOI: 10.1159/000321559] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2009] [Indexed: 12/22/2022] Open
Abstract
Cerebroretinal microangiopathy with calcifications and cysts (CRMCC) is a highly pleiotropic disorder, particularly affecting the eye, brain, bone, and gut. The potential catastrophic sequelae of the associated gastrointestinal phenotype, variably characterised by both chronic bleeding and liver failure, is becoming increasingly apparent. Here we report a probable case of CRMCC with pre- and postnatal growth restriction, bilateral exudative retinopathy, a pathognomonic pattern of intracranial calcification, white matter disease, osteopenia with a tendency to fractures, and chronic gastrointestinal bleeding secondary to abnormal dilated vasculature. The gastrointestinal endoscopic findings were characteristic of gastric antral vascular ectasia (GAVE). Treatment with a combination of oral oestrogen and progesterone ameliorated the gastrointestinal blood loss such that monthly blood transfusions could be stopped. The benefit of this relatively benign therapy in managing the potentially life-limiting consequences of an abnormal gastrointestinal vasculature in CRMCC is of great interest.
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Affiliation(s)
- T A Briggs
- Genetic Medicine, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Westerhoff M, Tretiakova M, Hovan L, Miller J, Noffsinger A, Hart J. CD61, CD31, and CD34 improve diagnostic accuracy in gastric antral vascular ectasia and portal hypertensive gastropathy: An immunohistochemical and digital morphometric study. Am J Surg Pathol. 2010;34:494-501. [PMID: 20351488 DOI: 10.1097/pas.0b013e3181d38f0a] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are unusual but important causes of gastrointestinal bleeding with characteristic endoscopic appearances and critically different therapies. However, overlapping features and poor endoscopic-histologic correlation make their distinction challenging. We sought to determine whether CD31, CD34 (vascular markers), and CD61 (platelet marker) could aid in their differentiation. Cases included 11 antral specimens with histologic diagnoses of GAVE, 11 histologically diagnosed as PHG, and biopsies of GAVE (15) or PHG (12) suspected on endoscopy but without histologic agreement. Controls consisted of endoscopically and histologically normal antrum. Image analysis of CD31 and CD34-stained sections was performed to determine mucosal microvessel density (MVD). CD61 revealed thrombi in 100% of histologically confirmed cases of GAVE and 60% of cases suspected of GAVE on endoscopy alone; control biopsies were negative. CD61 was also positive in 26% of cases originally signed out as PHG. Review of hematoxylin and eosin slides from these CD61-positive PHG cases showed other features allowing their correct reclassification as GAVE. MVD was significantly higher in GAVE than PHG. MVD in histologically confirmed PHG did not differ significantly from endoscopically suspected PHG. Review of hematoxylin and eosin slides from the latter showed active gastritis obscuring recognition of ectatic vessels. In conclusion, CD61 reliably differentiates GAVE from PHG. MVD analysis can also assist in their distinction. In PHG, the increased vascularity may be subtle in an inflammatory background; vascular markers may serve as adjunct markers for identifying the aberrant vessels.
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50
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Hernández-Gea V, Villanueva Sánchez C. [Angor pectoris after endoscopic sclerotherapy in a patient with a transjugular intrahepatic portosystemic shunt]. Med Clin (Barc) 2010; 134:326-7. [PMID: 19243796 DOI: 10.1016/j.medcli.2008.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Accepted: 12/03/2008] [Indexed: 11/30/2022]
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