Treatment of watermelon stomach

Gastric Antral Vascular Ectasia in Systemic Sclerosis: Current Concepts

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

[Watermelon stomach: Chronic renal failure and/or imatinib?]

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.

Transjugular intrahepatic portosystemic shunt as bridge-to-surgery in refractory gastric antral vascular ectasia

Gastric antral vascular ectasia (GAVE) may cause gastrointestinal bleeding (GIB). The treatment of GAVE relies on endoscopic approaches such as electrocoagulation (argon plasma coagulation, laser therapy, heater probe therapy, radiofrequency ablation), cryotherapy, and band ligation. In refractory cases, antrectomy may be considered. In the event of an associated cirrhosis and portal hypertension, it has been suggested that antrectomy could be an option, provided the mortality risk isn't considered too great. We report the case of a 67-year-old cirrhotic patient who presented with GAVE related GIB, unresponsive to multiple endoscopic treatments. The patient had a good liver function (model for end-stage disease 10). After a multidisciplinary meeting, a transjugular intrahepatic portosystemic shunt (TIPS) procedure was performed, in order to treat the cirrhosis associated ascites. The outcome was successful. An antrectomy was then performed, with no recurrence of GIB and no transfusion need during three months of follow up. In this case, the TIPS procedure achieved a complete ascites regression, allowing a safer surgical treatment of the GAVE-related GIB.

External-beam radiotherapy: A realistic therapeutic option for the gastric antral vascular ectasia

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.

Long-term effect of argon plasma coagulation (APC) in the treatment of gastric antral vascular ectasia (GAVE)

BACKGROUND AND STUDY AIMS

Gastric antral vascular ectasia (GAVE) is a distinct vascular abnormality, mainly involving the gastric antrum. It is a rare but well-known cause of occult gastrointestinal bleeding. Various endoscopic treatment modalities have been tried in this condition. The aim of the study is to show the long-term effect of argon plasma coagulation (APC) on GAVE.

PATIENTS AND METHODS

Twenty-nine patients with endoscopically proved GAVE were enrolled in the study. Clinical assessment of GAVE patients, haemoglobin (Hb) level and transfused blood units were recorded after APC using 60-80-W power setting. A second session was done 1month after the therapeutic procedure to ensure complete ablation of all lesions.

RESULTS

The documented Hb levels and number of blood units transfused 3months after APC were recorded. At endoscopy, all patients had the classic type of GAVE. The mean Hb level increased from 7.5±1.7gdl(-1) before APC to 10.2±0.8gdl(-1) after APC (p value <0.001). The transfusion requirements significantly decreased to 0.2±0.5units/patient (p value <0.001).

CONCLUSION

Endoscopic APC is a safe, effective and inexpensive modality in treating GAVE and could be an alternative to the currently available endoscopic methods.

Watermelon stomach in systemic sclerosis: its incidence and management

BACKGROUND

To date, there are no large endoscopic studies in systemic sclerosis (SSc), and both prevalence and characteristics of watermelon stomach in SSc have not been determined.

AIMS

To determine the prevalence, clinical presentation, endoscopic appearance, therapy success and long-term outcome in SSc patients with watermelon stomach and make predictions about which SSc patients are at risk for watermelon stomach. Patients and methods From 1990 to 2008, 264 patients were seen for evaluation of SSc. Data were collected as regards patients' characteristics, time of watermelon stomach onset, features, therapy and outcome of watermelon stomach.

RESULTS

Fifteen SSc patients (5.7%) exhibited watermelon stomach. SSc onset preceded watermelon stomach manifestations in 13 patients (86.7%). Most patients (86.7%) presented with iron-deficiency anaemia, two other patients experienced gastrointestinal haemorrhage. Gastroscopy disclosed typical 'watermelon stomach' characterized by prominent, erythematous stripes, radiating in a spoke-like fashion from the antrum to the pylorus. All patients received conservative therapy; because of deterioration of watermelon stomach, eight patients (53.3%) underwent endoscopic procedures. During follow-up, five patients (33.3%) exhibited recurrences of watermelon stomach.

CONCLUSIONS

Our series indicates that watermelon stomach should be considered when unexplained iron-deficiency anaemia occurs in SSc patients. Moreover, because watermelon stomach may be the first manifestation of SSc, patients with unexplained watermelon stomach should systematically undergo physical examination and autoantibody testing to detect the underlying SSc.

Second-generation argon plasma coagulation: two-center experience with 600 patients

BACKGROUND AND AIM

Second-generation argon plasma coagulation (APC; APC 2/VIO APC) with its modes 'forced', 'pulsed', and 'precise' is a further development of the ICC/APC 300 system (first-generation APC). Until now, only limited data has existed on the use of APC 2.

METHODS

Fundamental data on the characteristics of the various APC 2 modes and clinical data from more than 600 patients treated in two high-volume endoscopy centers were analyzed. On the basis of these data, recommendations for the use of APC in daily gastroenterological practice were made.

RESULTS

In comparison to the ICC system, second-generation APC offers a broadened bandwidth of settings including different APC modes and a range of power settings from 1 to 120 W. Using the various modes of APC 2 in a variety of gastrointestinal diseases, minor complications were observed in 9-21% of patients. Major complications occurred in 1-7% of patients.

CONCLUSIONS

In a two-center experience treating a large group of patients with a wide variety of gastrointestinal conditions, the different APC 2 modes appeared to be safe and effective. Certain preventive measures before and during clinical application are recommended in order to avoid complications.

Endoscopic mucosal ablation for the treatment of gastric antral vascular ectasia with the HALO90 system: a pilot study

BACKGROUND

Gastric antral vascular ectasia (GAVE) often results in GI bleeding and chronic anemia. Treatment options are limited and include medical, endoscopic, and surgical therapies.

OBJECTIVE

To assess the utility of endoscopic mucosal ablative therapy by using the HALO(90) system for patients with GAVE and recurrent bleeding.

DESIGN

Prospective open-label case series.

SETTING

Tertiary referral center.

PATIENTS

Six consecutive patients with GAVE, bleeding, and blood transfusion dependence.

MAIN OUTCOME MEASUREMENTS

Comparison of preablation and postablation Hb levels and transfusion requirements. To assess the number of ablation sessions needed to stabilize the Hb level and eliminate the need for blood transfusion.

RESULTS

Six patients, (4 men, mean age 58 years, range 47-65 years) underwent endoscopic mucosal ablation of antral lesions (mean procedure time 29 minutes; mean treatments 1.7, range 1-3). The mean Hb level improved from 8.6 to 10.2 g/dl (mean 2 months after the last ablation). Five of 6 patients are no longer dependent on blood transfusions to maintain a stable Hb level.

LIMITATIONS

This is a pilot study, with a small number of patients at a single center, with limited patient follow-up.

CONCLUSIONS

This study suggests that endoscopic mucosal ablation by using the HALO(90) system is a promising treatment option for chronic bleeding related to GAVE.

[Diagnosis of anemia in alcoholic cirrhosis]

PURPOSE

Anemia in patients with alcoholic liver cirrhosis is a common issue. The diagnosis could be difficult because of the multiplicity of causes, usually associated, and specificities in the diagnostic approach. This subject has not been reviewed for almost two decades. We propose a review based upon analysis of the literature and our clinical experience.

CURRENT KNOWLEDGE AND KEY POINTS

Because of the alcoholism and the biological consequences of the liver disease, laboratory findings, especially the mean corpuscular volume, should be interpreted with caution in the diagnostic approach. Despite these drawbacks, the diagnosis of anemia is detailed according to the usual plan: normocytic, macrocytic and microcytic anemias. Finally, we propose practical guidelines.

FUTURE PROSPECTS AND PROJECTS

Further prospective studies should assess the real burden of nutritional deficiencies, easily treatable. The prognostic significance of hemolytic anemias in patients with alcoholic liver cirrhosis should be studied.

Gastric antral vascular ectasia (GAVE) associated with systemic sclerosis: relapse after endoscopic treatment by argon plasma coagulation

In this report, we present a case of gastric antral vascular ectasia (GAVE) associated with systemic sclerosis and interstitial pneumonitis. This case showed resistance to endoscopic treatment using argon plasma coagulation (APC). After initial recognition of GAVE as the origin of persistent anemia, three sessions of APC were performed and dilated vessels on the antrum were eliminated completely. Five months after primary treatment, follow-up endoscopy revealed deformity of the gastric antrum caused by ulcer scars induced by APC, with no vascular ectasia. Ten months later, the patient showed anemia and recurrence of GAVE on endoscopy. Ablation using APC was performed again, thereby eradicating recurrent GAVE completely. At a two months' follow-up, however, recurrent GAVE was indicated. In spite of GAVE eradication by APC, a third recurrence of GAVE was observed after 32 months. During the follow-up period, systemic sclerosis and interstitial pneumonitis were controlled clinically by administration of methyl prednisolone with no aggravation.