Diagnosis and management of gastric antral vascular ectasia

Incidental diagnosis of gastric antral vascular ectasia in a case of chronic kidney disease from Nepal: a case report

INTRODUCTION

Gastric antral vascular ectasia is an uncommon clinical disease that affects elder people and is characterized by severe chronic upper gastrointestinal bleeding mainly affecting the gastric antrum. It is generally unusual among patients undergoing maintenance hemodialysis for chronic kidney disease.

CASE PRESENTATION

Here, we aim to present an uncommon case of incidental diagnosis of the gastric antral vascular ectasia and erosive gastritis in a 71-year-old Hindu male patient belonging to the Gurung ethnicity of Nepal undergoing maintenance hemodialysis due to chronic kidney disease. The patient presented with a history of melena and fatigue. On investigation, a low hemoglobin level of 7.3 gm% was used for blood transfusion. The patient was on regular hemodialysis after admission at our institution. Upper gastrointestinal bleeding was suspected after analyzing patient's history and investigations. Therefore, an upper gastrointestinal endoscopy was performed that showed linear ectatic punctuate lesions radiating from the body of the stomach to the antrum, and hence, an incidental diagnosis of the gastric antral vascular ectasia was made. Initial fluid resuscitation, iron therapy, and a triple regimen were administered. Proper management with argon plasma coagulation therapy was scheduled at another institution due to lack of respective facilities in our institution.

DISCUSSION

Gastric antral vascular ectasia is an unusual cause of upper gastrointestinal bleeding, primarily affecting the gastric antrum and pylorus with rare cases affecting the duodenum, jejunum, and gastric fundus. It is generally associated with other chronic disease conditions. Several hypotheses have been proposed for the pathogenesis of gastric antral vascular ectasia, especially its association with chronic kidney disease, as in our case, which is considered to be rare. Management varies from medical to endoscopic interventions to even surgery.

CONCLUSION

Prompt proper diagnosis and treatment for the gastric antral vascular ectasia should be sought, as it is frequently misdiagnosed or missed during upper gastrointestinal endoscopy. Our case report presents a case of gastric antral vascular ectasia in chronic kidney disease undergoing maintenance hemodialysis, which is quite uncommon, as literature has suggested the same point.

Comparing Endoscopic Treatment Modalities for Gastric Antral Vascular Ectasia: Efficacy, Safety, and Outcomes in a Network Meta-analysis

OBJECTIVE

Gastric antral vascular ectasia (GAVE) is characterized by vascular ectasias accounting for 4% of nonvariceal upper gastrointestinal bleeds, which can range from occult bleeds to severe acute upper gastrointestinal bleeding. In turn, GAVE can lead to severe morbidity and recurrent hospitalization. Current endoscopic treatments for GAVE include argon plasma coagulation (APC), endoscopic band ligation (EBL), and radiofrequency ablation. With this significant burden in mind, a systematic review and network meta-analysis were conducted to compare the efficacy and safety of various modalities in the treatment of GAVE.

METHODS

All studies that involved adults and children with endoscopic characteristics of GAVE undergoing treatment with APC, EBL, radiofrequency ablation, or a combination of 2 treatment modalities were included.

RESULTS

There was no statistical difference in the rate of adverse events and the number of red blood cell transfusions across all 3 groups (APC, EBL, and APC + EBL). However, statistical differences were noted for outcomes of bleeding recurrence, length of hospitalization, and change in hemoglobin status. EBL exhibited a significant decrease in bleeding recurrence when compared with APC. Moreover, shorter hospitalization stays were seen in APC + EBL and EBL groups compared with APC, and a beneficial change in hemoglobin status was also more often seen in APC + EBL and EBL groups compared with APC.

CONCLUSIONS

Based on this study, EBL was found to have superior efficacy when compared with APC for the treatment of GAVE; however, there was no significant difference in rates of adverse events between APC, EBL, and combination therapy.

Managing Symptoms of Systemic Sclerosis for the Allergist-Immunologist

PURPOSE OF REVIEW

Systemic sclerosis (SSc) is a chronic, multisystem, autoimmune disease characterized by fibrosis, vasculopathy and immune system dysregulation. We provide a comprehensive review of features of systemic sclerosis that can potentially present to the allergist.

RECENT FINDINGS

A thorough understanding of the management options is crucial for clinicians involved in the care of patients with SSc to optimize clinical outcomes. Management of systemic sclerosis has drastically changed in the last decade and continues to evolve. This review provides an overview of management strategies for the various symptoms including skin, upper and lower airway, gastrointestinal and vascular manifestations. Institution of treatment early in the disease, including referral to rheumatology or specialized scleroderma centers, can help to both prevent and manage disease complications, and improve patient quality-of-life. While the landscape of systemic sclerosis management has evolved, we continue to recognize that there is still a need for better biomarkers and targeted therapies.

Non-variceal Upper Gastrointestinal Bleeding and Its Endoscopic Management

Upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality. Clinical symptoms that patients may present with include: hematemesis, coffee-ground emesis, melena, and hematochezia. Clinical signs can range from tachycardia to shock. The anatomical landmark that differentiates upper gastrointestinal (GI) bleeds from lower bleeds is the ligament of Treitz. The first steps of treating a patient who presents with signs of UGIB are resuscitation with appropriate fluids and blood products as necessary. The consideration of endoscopy and the urgency at which it should be performed is also vital during initial resuscitation. Endoscopic therapy should ideally be performed within 24 hours of presentation after initial stabilization with crystalloids and blood products. Intravenous proton pump inhibitors are the mainstay in the initial management of upper GI bleeding from a non-variceal etiology, and they should be administered in the acute setting to decrease the probability of high-risk stigmata seen during endoscopy. Pro-kinetic agents can be given 30 minutes to an hour before endoscopy and may aid in the diagnosis of UGIB. There are 3 broad categories of endoscopic management for UGIB: injection, thermal, and mechanical. Each endoscopic method can be used alone or in combination with others; however, the injection technique with epinephrine should always be used in conjunction with another method to increase the success of achieving hemostasis. In this review article, we will review the steps of triage and initial resuscitation in UGIB, causes of UGIB and their respective management, several endoscopic techniques and their effectiveness, and prognosis with a primary focus limited to non-variceal bleeding.

Recurrent gastric antral vascular ectasia: a single center experience

Introduction

Gastric antral vascular ectasia (GAVE) is a rare cause of chronic or acute gastrointestinal bleeding. This condition accounts for ∼4% of upper gastrointestinal bleeding cases. This disease is often associated with systemic diseases, such as liver cirrhosis, chronic kidney failure, autoimmune conditions, diabetes mellitus, hypothyroidism, and cardiovascular diseases. However, its etiopathogenesis remains controversial.

Materials and method

We retrospectively reviewed the cases of GAVE treated at our digestive surgery unit. A total of nine patients were identified with a male/female ratio of 1.25:1 and an average age of 75.51 years (SD ± 9.85). All patients underwent endoscopic argon plasma coagulation (APC) treatment. At the time of the review, data on eight patients were available after 36 months of follow-up.

Results

APC appears to be safe and effective for hemostasis of bleeding vascular ectasia. Only one (11.1%) patient required surgical intervention due to hemodynamic instability after multiple unsuccessful endoscopic treatments. No intraoperative and postoperative complication or bleeding relapse was experienced.

Discussion

Based on our findings, we concluded that endoscopic APC is technically simple, but requires multiple re-interventions due to the incidence of relapses. Furthermore, larger randomized studies should be conducted to assess the role of elective surgery as the first intervention in stable patients with severe pathology and the timing of surgery after failed endoscopic treatment.

Resolution of gastric antral vascular ectasia following cessation of imatinib

A female patient in her 80s presented with chronic iron-deficiency anaemia secondary to gastric antral vascular ectasia (GAVE), despite repeated endoscopic treatment. Her medical history was notable for chronic myeloid leukaemia, for which she took imatinib. Due to a possible association between imatinib and GAVE described in a small number of case reports, cessation of imatinib was trialled. This led to a significant improvement in the patient's anaemia and resolution of GAVE on repeat endoscopy. GAVE is an uncommon cause of gastrointestinal bleeding, the aetiology of which is uncertain. This report describes an approach to the differential diagnosis of chronic iron-deficiency anaemia and an overview of GAVE syndrome. It illustrates the benefit of broadening the differential when the diagnosis is uncertain and the utility of case reports in informing the differential diagnosis.

Native Aortic Valve Endocarditis Secondary to Gastric Antral Vascular Ectasia Manipulation During Endoscopic Argon Plasma Coagulation

Gastric antral vascular ectasia (GAVE) is an uncommon cause of upper gastrointestinal (GI) bleeds. Due to the high vascularity of the region, transient bacteremia due to manipulation of the GI tract can very rarely cause the translocation of bacteria. We present a rare case in which endoscopic manipulation to treat GAVE led to native valve infective endocarditis (IE). Our patient had a prior history of GAVE and presented with worsening dizziness and shortness of breath (SOB). After an esophagogastroduodenoscopy (EGD) and subsequent argon plasma coagulation (APC) for active preantral bleeding, the patient was noted to have repeated fevers, a new cardiac murmur, and positive blood cultures for Staphylococcus epidermidis, leading to a diagnosis of native infective endocarditis. With high clinical suspicion and early recognition of a new cardiac murmur, a transesophageal echocardiogram (TEE) was key in identifying vegetation. This case highlights the importance of combining history, a physical exam, and diagnostic lab tests and imaging to identify endocarditis. Management included two months of intravenous (IV) vancomycin and repeat TEE for close monitoring of vegetation improvement.

In Search of Nodular Gastric Antral Vascular Ectasia: A Distinct Entity or Simply Hyperplastic Polyps Arising in Gastric Antral Vascular Ectasia?

CONTEXT.—

Nodular gastric antral vascular ectasia (GAVE) is a reported phenotype of GAVE that has histologic features overlapping with gastric hyperplastic polyps (GHPs), with additional features often seen in flat mucosa of GAVE.

OBJECTIVE.—

To determine if nodular GAVE and GHPs are distinct lesions by evaluating the prevalence of features reported in nodular GAVE in GHPs with or without associated GAVE.

DESIGN.—

A review of all lesions diagnosed as GHPs between 2014 and 2017 was performed. Slides were analyzed for a number of features including established histologic features of GAVE without knowledge of clinical or endoscopic features.

RESULTS.—

A total of 90 polyps were analyzed including 18 from patients with GAVE (20%). GAVE polyps were larger than non-GAVE polyps (average size, 1.3 cm versus 0.68 cm; P < .001), with more common extensive ulceration and associated granulation tissue (61.11% [n = 11] versus 4.17% [n = 3]; P = .004), fibrin thrombi (50% [n = 9] versus 15% [n = 11]; P = .003), moderate to marked vascular ectasia (83% [n = 15] versus 35% [n = 11]; P = .001), and fibrohyalinosis (72% [n = 13] versus 28% [n = 20]; P = .001). All polyps showed foveolar hyperplasia and smooth muscle proliferation. There were no features that were exclusively found in GAVE or non-GAVE cases.

CONCLUSIONS.—

Nodular GAVE appears to represent GHPs arising in a background of GAVE, with superimposed features found in flat mucosa of GAVE stomachs. The presence of fibrin thrombi, marked vascular ectasia, fibrohyalinosis, and/or ulceration in a GHP is suggestive but not diagnostic of GAVE, and the absence of these features does not rule out GAVE.

Successful Surgical Management of Gastric Antral Vascular Ectasia in a Patient with End-Stage Renal Disease: A Case Report and Literature Review

BACKGROUND Gastric antral vascular ectasia (GAVE) is a rare clinical entity that presents with acute upper-gastrointestinal bleeding or chronic anemia. It is characterized by endoscopic watermelon appearance of the stomach. It is usually associated with other comorbidities; however, few articles have previously described GAVE in patients with end-stage renal disease. Its management is controversial, and endoscopic management is considered the treatment of choice. CASE REPORT A middle-age female patient, on regular hemodialysis for ESRD, was referred to the surgical out-patient clinic as a refractory GAVE after failure of endoscopic management as she became blood transfusion-dependent. She underwent laparoscopic subtotal gastrectomy with a Billroth II reconstruction of gastrojejunostomy. She had a smooth postoperative course and was followed up in the clinic for 12 months with no complications. Her hemoglobin level was stable at 9.4 g/dL without further blood transfusion. CONCLUSIONS Gastric antral vascular ectasia is usually associated with other comorbidities; however, an association between GAVE and CKD is rare. Its management is controversial, and endoscopic management is considered the preferred method of treatment. Laparoscopic subtotal gastrectomy is an effective management modality for GAVE, with dramatic improvement and good outcomes in terms of bleeding, blood transfusion requirements, and nutritional status.

A Case of Refractory Gastric Antral Vascular Ectasia Treated Successfully With Distal Gastrectomy and Billroth II Reconstruction

Gastric antral vascular ectasia is a rare cause of upper gastrointestinal bleeding and an important cause of transfusion dependence. Although surgery should be considered when patients with gastric antral vascular ectasia become transfusion-dependent even after endoscopic treatment, surgery for such patients with cirrhosis on dialysis has not been reported. Our patient, a 62-year-old man with a history of cirrhosis and chronic kidney failure, experienced recurrent bloody stool. Upper endoscopic findings indicated a diagnosis of gastric antral vascular ectasia; therefore, we initiated therapy with argon plasma coagulation. Anemia developed, and despite a second argon plasma coagulation treatment, it remained difficult to control. During the six weeks of hospitalization, the patient received more than 40 units of red blood cells. The gastroenterologist determined that further treatment with argon plasma coagulation would increase the risk of gastric perforation; therefore, we performed distal gastrectomy with Billroth II reconstruction. The patient was discharged from the hospital 15 days after surgery and had no signs of anemia for more than one year after discharge. The case of our patient shows that although endoscopic therapy is the usual treatment for gastric antral vascular ectasia, surgery should be considered when anemia is difficult to control.

Gastric antral vascular ectasia (Watermelon stomach); an unusual cause of upper gastrointestinal bleeding in elderly: A case report

Introduction

Gastric antral vascular ectasia (GAVE) is an unusual cause of upper gastrointestinal (GI) bleeding in an elderly patient.

Case presentation

A 73-year-old female with erosive gastritis, hypertension, and unstable angina arrived at the emergency department with shortness of breath, easy fatigability, and melaena. Physical examination indicated pallor but no signs of distress, with an unremarkable systemic examination. Routine blood testing indicated anemia. The patient underwent upper gastrointestinal endoscopy, which revealed linear red ectatic vessels radiating from the antrum towards the body. A diagnosis of GAVE was made. Blood transfusions and argon plasma coagulation were undertaken.

Clinical discussion

This condition is an uncommon cause of upper GI bleeding with the antrum being the most prevalent site. The pathophysiology of GAVE is yet unknown, however, many hypotheses have been postulated. GAVE is frequently misdiagnosed as gastritis. GAVE treatment comprises initial resuscitation and symptomatic treatment with intravenous fluids and blood products. Endoscopy has increasingly been the first-line therapeutic option for GAVE in recent years, including argon plasma coagulation.

Conclusion

The diagnosis of gastric antral vascular ectasia is frequently overlooked during upper GI endoscopy, despite the fact that it should always be explored, especially in cases of unexplained GI bleeding in the elderly.

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An unusual cause of upper gastrointestinal bleeding in an elderly patient.

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Frequently misdiagnosed as gastritis.

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Linear red ectatic vessels radiating from gastric antrum towards the body.

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Argon plasma coagulation is a good treatment modality.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

The misclassification of gastric antral vascular ectasia

BACKGROUND

Gastric antral vascular ectasia (GAVE) is characterized by angiodysplastic lesions and is a rare form of gastrointestinal bleeding. Given the multiple patterns, GAVE can be misclassified.

AIM

We analyzed the misclassification of GAVE among patients undergoing esophagogastroduodenoscopy (EGD).

METHODS

We performed a retrospective review of 941 EGDs between 2017 and 2019. Inclusion criteria included findings of GAVE on EGD±biopsy. Correct classification was based on visual EGD findings. Outcome variables included misclassification rate, endoscopist's background, and concordance between EGD and pathology. Cohen's Kappa test was used for concordance analysis.

RESULTS

A total of 110 patients had EGD findings of GAVE with a corresponding 184 EGDs. The misclassification rate among EGDs was 74/184 (40%). Furthermore, 81/110 patients were correctly classified with their first workup, whereas 29/110 patients needed repeat testing. In cases of misclassification, GAVE was mostly referred to as erythema (43%), with ulceration, gastritis, or polyps. Sixty-six (60%) patients had biopsies with a concordance of 76% between EGD and biopsy (κ=0.35).

CONCLUSIONS

Our findings indicate GAVE was misclassified up to 40% on EGDs with hepatologists and gastroenterologists having similar misclassification rates. Proper identification is crucial given susceptibility to upper gastrointestinal bleeding.

RELEVANCE FOR PATIENTS

This study emphasizes the importance of accurate classification of GAVE to ensure proper treatment of these lesions which can improve clinical outcomes.

Gastric antral vascular ectasia in systemic sclerosis: a study of its epidemiology, disease characteristics and impact on survival

BACKGROUND

To describe the epidemiology, determinants and survival impact of gastric antral vascular ectasia (GAVE) in systemic sclerosis (SSc).

METHODS

Consecutive SSc patients prospectively enrolled in the Australian Scleroderma Cohort Study (ASCS) were included. Univariable and multivariable logistic regression were used to determine the associations of GAVE with clinical manifestations and serological parameters. Kaplan-Meier (K-M) survival curves were used to estimate survival.

RESULTS

The prevalence of GAVE in this SSc cohort of 2039 SSc patients was 10.6% (n = 216) over a median follow-up period of 4.3(1.7-8.4) years. SSc patients with a history of GAVE compared with those without a history of GAVE were older at SSc onset [49.5 (40.0-58.2) vs 46.7 (36.0-56.7) years, p = 0.05]; more likely to have diffuse disease subtype (dcSSc) (35.3% vs 24.1%, p < 0.001); be negative for Scl-70, U1RNP and Scl/PM antibody (4.0% vs 16.1%, p < 0.001, 3.5% vs 7.4%, p = 0.041, 0.0% vs 2.0%, p = 0.042; and respectively) and positive for RNAP III antibody (24.9% vs 8.3%, p < 0.001). Those with GAVE had a worse HRQoL (p = 0.002). Independent determinants of GAVE included the presence of RNAP III antibody (OR 3.46, p < 0.001), absence of Scl-70 antibody (OR 0.23, p = 0.001), presence of GIT dysmotility (OR 1.64, p = 0.004), and digital ulcers; pits; or digital amputation (OR 1.59, p = 0.014).

CONCLUSIONS

GAVE is an underestimated and underappreciated SSc manifestation of SSc, which occurs with a relatively high frequency. Identifying an at-risk GAVE phenotype, as presented herein, is of practical importance as screening may prove advantageous given GAVE can be easily diagnosed and treated.

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Objectives and study aims  Recent pilot studies have assessed the feasibility of a novel 1.9-/1.5-μm dual emission endoscopic laser treatment ( _1.9-/1.5-μm DEELT) for endoscopic hemostasis, ablation and resection. In this study, we investigated the safety and efficacy of _1.9-/1.5-μm DEELT in patients with chronic anemia due to gastrointestinal vascular lesions in a real-life multicenter cohort setting.

Patients and methods  Consecutive patients with moderate/severe iron-deficiency anemia undergoing _1.9-/1.5-μm DEELT for upper and lower gastrointestinal bleeding due to vascular lesions were enrolled in three academic referral centers. Safety and successful ablation of vascular lesions were the primary outcomes. Long-term hemoglobin level, blood transfusion requirements, endoscopic severity scores of complex vascular disorders and technical lasing parameters were also assessed. Long-term hemoglobin variations have been further assessed, with repeated measure analysis of variance and univariate analyses.

Results  Fifty patients (median age 74; range 47 to 91 years) with gastric antral vascular ectasia (GAVE) (22), angioectasia (22) and radiation proctopathy (6) underwent 58 _1.9-/1.5-μm DEELT between 2016 and 2020. All procedures were technically feasible leading to successful ablation of the targeted lesion/s, with no incident or adverse event potentially related to the _1.9-/1.5-μm DEELT technique. Within a 6-month follow-up, hemoglobin values significantly rose (+ 1.77 at 1 month and + 1.70 g/dL at 6 months, P  < 0.01), the blood supply requirement decreased (at least one transfusion in 32 versus 13 patients, P  < 0.01), and GAVE lesions showed a clear endoscopic improvement (from 5 points to 1 points, P  < 0.01).

Conclusions  The 1.9-/1.5-μm laser system is a safe and effective endoscopic tool for haemostatic ablation of bleeding vascular lesions within the gastrointestinal tract in tertiary referral centers.

Gastric Antral Vascular Ectasia as the First Presentation of Primary Biliary Cholangitis

Primary biliary cholangitis (PBC), a chronic, autoimmune, cholestatic disease, typically occurs in elderly women and commonly presents with pruritus, fatigue, and cholestasis and its complications. Gastric antral vascular ectasia (GAVE), an uncommon cause of upper gastrointestinal bleeding, leading to transfusion-dependent chronic iron deficiency anemia, as the first presentation of PBC is unusual. We present the case of an elderly female with recurrent melena and transfusion-dependent anemia for a year without any history of jaundice, ascites, or hepatic encephalopathy. Investigations revealed iron-deficiency anemia, elevated transaminases, alkaline phosphatase (ALP), coarse liver, splenomegaly, and portal vein dilatation on ultrasound. An endoscopic evaluation revealed erythematous linear stripes in the antrum suggestive of GAVE, without esophageal or gastric varices. FibroScan (Echosens, Paris, France) revealed advanced F3 fibrosis. Further etiological workup showed positive antinuclear and antimitochondrial antibodies, elevated IgM levels, and negative viral markers (hepatitis B, C, A, and E). Clinically significant portal hypertension was revealed by the hepatic venous pressure gradient (HVPG), while transjugular liver biopsy (TJLB) revealed lymphocytic infiltration of bile duct epithelium with the destruction of small and medium-sized bile ductules. Iron supplementation, low-dose ursodeoxycholic acid, and argon plasma coagulation were used to treat the patient. At the three-month follow-up, no melena was reported and her hemoglobin and liver function tests remained normal. Patients with PBC presenting with GAVE and recurrent melena as a presenting symptom are rarely reported. An awareness of this presentation is important for its early diagnosis and effective treatment.

Endoscopic cryotherapy: Indications, techniques, and outcomes involving the gastrointestinal tract

Endoscopic cryotherapy is a technique utilized for the ablation of target tissue within the gastrointestinal tract. A cryotherapy system utilizes the endoscopic application of cryogen such as liquid nitrogen, carbon dioxide or liquid nitrous oxide. This leads to disruption of cell membranes, apoptosis, and thrombosis of local blood vessels within the target tissue. Several trials utilizing cryotherapy for Barrett's esophagus (BE) with variable dysplasia, gastric antral vascular ectasia (GAVE), esophageal carcinoma, radiation proctitis, and metastatic esophageal carcinomas have shown safety and efficacy. More recently, liquid nitrogen cryotherapy (cryodilation) was shown to be safe and effective for the treatment of a benign esophageal stricture which was refractory to dilations, steroid injections, and stenting. Moreover, liquid nitrogen cryotherapy is associated with less post procedure pain as compared to radiofrequency ablation in BE with comparable ablation rates. In patients with GAVE, cryotherapy was found to be less tedious as compared to argon plasma coagulation. Adverse events from cryotherapy most commonly include chest pain, esophageal strictures, and bleeding. Gastric perforations did occur as well, but less often. In summary, endoscopic cryotherapy is a promising and growing field, which was first demonstrated in BE, but the use now spans for several other disease processes. Larger randomized controlled trials are needed before its role can be established for these different diseases.

Prevalence of metabolic syndrome in cirrhotics with gastric antral vascular ectasia

BACKGROUND AND AIMS

Gastric antral vascular ectasia (GAVE) is characterized by angliodysplastic lesions that can cause upper gastrointestinal bleeding (UGIB). The mechanism behind GAVE and its association with other diseases remains unknown. We investigated the association of metabolic syndrome in cirrhotic GAVE patients when compared to esophageal variceal hemorrhage (EVH) patients.

METHODS

We performed a retrospective review of 941 consecutive esophagogastroduodenoscopies (EGDs) for UGIB at a medical center between 2017 and 2019. The GAVE group consisted of EGD or biopsy diagnosed cirrhotic GAVE patients, and the EVH group consisted of EVH patients with active bleeding or stigmata of recent hemorrhage on EGD. Baseline variables including co-morbidities and cirrhotic etiology were recorded. Continuous variables were compared using Wilcoxon test and categorical variables were compared using Chi-square or Fisher's exact test. Multiple logistic regression analysis evaluated the association between GAVE and covariates.

RESULTS

The final cohort had 96 GAVE and 104 EVH patients. Mean BMI was significantly higher in the GAVE cohort (32.6 vs 27.9, p < 0.0001) in addition to diabetes, hypertension, and hyperlipidemia (53.1% vs 37.5%; 76% vs 47.1%; 38.5% vs 14.4%; respectively, all p < 0.05). Non-alcoholic steatohepatitis (NASH) cirrhosis was more prevalent in GAVE than EVH patients (50% vs 24%, p = 0.0001). Multiple logistics regression revealed female sex, increased BMI, hypertension, and hyperlipidemia all having significantly higher risk of GAVE (all p < 0.05).

CONCLUSION

Our data indicates that when compared to cirrhotics patients with EVH, cirrhotics with GAVE have increased risk of metabolic syndrome. This may play a role in the underlying pathophysiology of GAVE.

Comparison of portal hypertensive gastropathy and gastric antral vascular ectasia: an update

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are two distinct entities that are frequently mistaken with each other, because they present with similar manifestations. This issue may cause catastrophic outcomes, as each one of them has a unique pathophysiology, thereby making their management approaches completely different. There are clinical clues that help physicians distinguish these two. Direct vision via upper endoscopy is often mandatory to establish the diagnosis, and sometimes biopsy is required. In this review, we sought to discuss different aspects of both conditions and highlight clinical evidence that may help in identifying and managing the disease appropriately.

Accuracy of virtual chromoendoscopy in differentiating gastric antral vascular ectasia from portal hypertensive gastropathy: A proof of concept study

BACKGROUND

Accurate detection of gastric antral vascular ectasia (GAVE) is critical for proper management of cirrhosis-related gastrointestinal bleeding. However, endoscopic diagnosis of GAVE can be challenging when GAVE overlaps with severe portal hypertensive gastropathy (PHG).

AIM

To determine the added diagnostic value of virtual chromoendoscopy to high definition white light for real-time endoscopic diagnosis of GAVE and PHG.

METHODS

We developed an I-scan virtual chromoendoscopy criteria for diagnosis of GAVE and PHG. We tested our criteria in a cross-sectional cohort of cirrhotic adults with GAVE and PHG when high-definition white light endoscopy (HDWLE) diagnosis was in doubt. We then compared the accuracy of I-scan vs HDWLE alone to histology.

RESULTS

Twenty-three patients were included in this study (65.2% Caucasians and 60.9% males). Chronic hepatitis C was the predominant cause of cirrhosis (43.5%) and seven adults (30.4%) had confirmed GAVE on histology. I-scan had higher sensitivity (100% vs 85.7%) and specificity (75% vs 62.5%) in diagnosing GAVE compared to HDWLE. This translates into a higher, albeit not statistically significant, accuracy of I-scan in detecting GAVE compared to HDWLE alone (82% vs 70%). I-scan was less likely to lead to an accurate diagnosis of GAVE in patients on dialysis (P < 0.05) and in patients with elevated creatinine (P < 0.05). I-scan had similar accuracy to HDWLE in detecting PHG.

CONCLUSION

This pilot work supports that virtual chromoendoscopy may obviate the need for biopsies when the presence of GAVE is in doubt. Larger studies are needed to assess the impact of virtual chromoendoscopy on success of endoscopic therapy for GAVE.

Management of portal hypertensive upper gastrointestinal bleeding: Report of the Coorg Consensus workshop of the Indian Society of Gastroenterology Task Force on Upper Gastrointestinal Bleeding

Portal hypertensive bleeding is a major complication of portal hypertension (PHT) with high morbidity and mortality. A lot of advances have been made in our understanding of screening, risk stratification, and management strategies for portal hypertensive bleeding including acute variceal bleeding leading to improved overall outcomes in patients with PHT. A number of guidelines on variceal bleeding have been published by various societies in the past few years. The Indian Society of Gastroenterology (ISG) Task Force on Upper Gastrointestinal Bleeding (UGIB) felt that it was necessary to bring out a standard practice guidance document for the use of Indian health care providers especially physicians, gastroenterologists, and hepatologists. For this purpose, an expert group meeting was convened by the ISG Task Force to deliberate on this matter and write a consensus guidance document for Indian practice. The delegates including gastroenterologists, hepatologists, radiologists, and surgeons from different parts of the country participated in the consensus development meeting at Coorg in 2018. A core group was constituted which reviewed all published literature on portal hypertensive UGIB with special reference to the Indian scenario and prepared unambiguous statements on different aspects for voting and consensus in the whole group. This consensus was produced through a modified Delphi process and reflects our current understanding and recommendations for the diagnosis and management of portal hypertensive UGIB in Indians. Intended for use by the health care providers especially gastroenterologists and hepatologists, these consensus statements provide an evidence-based approach to risk stratification, diagnosis, and management of patients with portal hypertensive bleeding.

Gastric antral vascular ectasia in hepatitis C virus related liver cirrhosis: Fetching for predictors

Background and Aim

Gastric antral vascular ectasia (GAVE) is observed in patients with liver cirrhosis and portal hypertension. The exact pathophysiologic mechanism that underlies this condition is unknown. In our study, we estimate the prevalence of GAVE in hepatitis C virus (HCV) cirrhosis and attempted to determine if any of the hepatocellular manifestations, liver functions, serum gastrin, abdominal ultrasound and endoscopic picture have a relation to, or could predict, the occurrence of GAVE in cirrhotic patients.

Methods

This study includes 500 HCV‐related liver cirrhosis patients. According to endoscopic assessment, we detected 30 patients with GAVE (Group 2). From the 470 patients without GAVE, we randomly selected 120 patients (Group 1), to avoid statistical bias, for comparison with Group 2. Comparison included clinical manifestations, laboratory findings, serum gastrin, ultrasound findings, and endoscopic findings (esophageal and/or gastric varices and gastropathy).

Results

The percentage of GAVE in HCV‐related liver cirrhosis is 0.06%. We can predict GAVE by platelets, palmer erythema, diabetes mellitus (DM), marked ascites > with area under the curve of 0.67, 75.5, 0.62, and 0.40%, and accuracy of 82.5, 72, 70.7, and 79.3%, respectively. There was no correlation found between occurrence of GAVE and endoscopic findings. Also, there was no correlation found between occurrence of GAVE and serum gastrin levels, which reflect another pathophysiology, and we found no statistically significant correlation with GAVE.

Conclusions

Palmer erythema, low platelets, DM, and ascites might help in the prediction of GAVE. GAVE is not linked to the presence, type or grade of varices, and gastropathy.

Endoscopic band ligation in the treatment of gastric antral vascular ectasia: a systematic review and meta-analysis

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.

Endoscopic Band Ligation Versus Argon Plasma Coagulation in the Treatment of Gastric Antral Vascular Ectasia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Aims

Argon plasma coagulation (APC) is the most commonly used endoscopic treatment for gastric antral vascular ectasia (GAVE). Endoscopic band ligation (EBL) has emerged as an alternative therapy. Our goal was to evaluate the feasibility, efficacy, and safety of APC and EBL for the treatment of GAVE. This is the first systematic review that included only randomized controlled trials (RCTs) on this topic.

Methods

A comprehensive search was performed using electronic databases to identify RCTs comparing APC and EBL for the treatment of GAVE following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Results

Four RCTs were included, with a total of 204 patients. EBL was related to higher endoscopic eradication rates risk difference [RD], 0.29; 95% confidence interval [CI] [0.14, 0.44]; I²=0%) and less bleeding recurrence than APC (RD, 0.29; 95% CI [0.15, 0.44]; I²=0%). Patients treated with EBL required fewer blood transfusions (mean difference [MD], 1.49; 95% CI [0.28, 2.71]; I²=96%) and hospitalizations (MD, 0.29; 95% CI [0.19, 0.39]; I²=0%). The number of sessions required for the obliteration of lesions was higher with APC. There was no difference in the incidence of adverse events.

Conclusions

EBL is superior to APC in the treatment of GAVE in terms of endoscopic eradication rates, recurrence of bleeding, and transfusion requirements.

Argon plasma coagulation with atezolizumab and chemoradiation in lung pleomorphic cancer showed a remarkable response: Case report

RATIONALE

Lung pleomorphic carcinoma (LPC) is generally resistant to chemotherapy or radiotherapy. However, a combination of immune checkpoint inhibitors and radiotherapy has a remarkable efficacy against LPC.

PATIENT CONCERNS AND DIAGNOSES

Here, we report the case of a 50-year old man diagnosed with progressive LPC. The tumor invaded the carina and predominantly obstructed the right main bronchus; therefore, a combination of palliative chemoradiotherapy and atezolizumab was initiated. However the trachea was gradually obstructed.

INTERVENTION AND OUTCOME

Argon plasma coagulation (APC) was performed to prevent tumor invasion. After three APC sessions, the tumor showed a necrotic change and was easily excised using biopsy forceps.

LESSONS

A combination of chemoradiotherapy, atezolizumab, and APC showed a good efficacy, and the patient had a good response to atezolizumab maintenance therapy. Multidisciplinary treatments, such as a combination of immune checkpoint inhibitors and APC, could have synergistic efficacy in lung cancer.

Gastric Antral Vascular Ectasia: Trends of Hospitalizations, Biodemographic Characteristics, and Outcomes With Watermelon Stomach

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.

Endoscopic treatment of gastric antral vascular ectasia in real-life settings: Argon plasma coagulation or endoscopic band ligation?

OBJECTIVE

The efficacy of argon plasma coagulation (APC) on gastric antral vascular ectasia (GAVE) may be impaired over time and depends greatly on the application settings. Endoscopic band ligation (EBL) may be an alternative, but study on its efficacy is limited. This study aimed to evaluate and compare the clinical efficacy of APC and EBL in treating GAVE.

METHODS

Changes in the need for blood transfusion, number of treatment sessions and hospitalizations were retrospectively assessed in 63 transfusion-dependent patients with GAVE (mean age: 67.1 y, 54.0% female) treated with either APC or EBL (45 and 18 patients, respectively) in four tertiary endoscopic centers.

RESULTS

Both methods substantially increased hemoglobin levels and decreased patients' need for a transfusion (22.0 ± 4.0 g/L and -5.62 ± 2.30 units of packed red blood cells [RBC] with APC, and 27.4 ± 6.1 g/L and -4.79 ± 2.46 units of packed RBC with EBL), without a significant statistical difference between the methods. However, fewer EBL sessions were required both for the cessation of need for a transfusion compared with those for the resolution of GAVE lesions (0.90 ± 0.10 vs 1.69 ± 0.31, P = 0.028).

CONCLUSIONS

Both APC and EBL are effective in GAVE treatment. EBL may be superior in terms of number of treatment sessions, but not in its influence on hemoglobin level and need for transfusion. Further prospective studies with large, homogeneous sample size and standardized APC settings are needed.

Gastric antral vascular ectasia in children, rare presentation

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.

Outcome of gastric antral vascular ectasia and related anemia after orthotopic liver transplantation

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.