Gastric Antral Vascular Ectasia Associated with Asymptomatic Mixed Connective Tissue Disease Refractory to Endoscopic Treatment: A Rare Case

Gastric antral vascular ectasia (GAVE) constitutes 4% of all nonvariceal upper GI bleedings. It is characterized by the presence of erythematous or hemorrhagic ectatic vessels within the antrum that are distributed either in a striped or diffuse punctate pattern. We report a 64-year-old female without any co-morbidities, who presented with multiple episodes of blood in stools. Laboratory studies revealed a hemoglobin level of 5 g/dL with a hematocrit of 18.3%. Iron studies revealed a serum iron level of 35 μg/dL. She underwent an upper GI endoscopy, and biopsy was consistent with gastric antral vascular ectasia. ANA (antinuclear antibody), RA (rheumatoid factor), and anti-centromere antibody were all strongly positive. Erythrocyte sedimentation rate was 56. She was asymptomatic as far as connective tissue disease was concerned. Her anemia improved, but argon plasma coagulation failed to sustain the suppression of GAVE, and she required a blood transfusion for severe anemia on two occasions. With regard to recurrent episodes of melena, she was started on oral methyl prednisolone in a tapering dosage. She improved with medications, and her hemoglobin is maintained at 11.3 g/dL. This is the first unique case of GAVE in a patient without any other systemic illness or portal hypertension refractory to endoscopic treatment responding to monotherapy with corticosteroids.

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Argon plasma coagulation (APC) : An effective endoscopic treatment of bleeding gastric antral vascular ectasia (GAVE)

Gastroenterology ◽

10.1016/s0016-5085(00)83966-9 ◽

2000 ◽

Vol 118 (4) ◽

pp. A463

Author(s):

Frederic Oberti ◽

Vincent Croquet ◽

Mehdi Kaassis ◽

Eric Vuillemin ◽

Mene Zua ◽

...

Keyword(s):

Endoscopic Treatment ◽

Argon Plasma Coagulation ◽

Argon Plasma ◽

Gastric Antral Vascular Ectasia ◽

Plasma Coagulation ◽

Vascular Ectasia

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Endoscopic treatment for gastric antral vascular ectasia

Therapeutic Advances in Chronic Disease ◽

10.1177/20406223211039696 ◽

2021 ◽

Vol 12 ◽

pp. 204062232110396

Author(s):

Mengyuan Peng ◽

Xiaozhong Guo ◽

Fangfang Yi ◽

Xiaodong Shao ◽

Le Wang ◽

...

Keyword(s):

Adverse Events ◽

Endoscopic Treatment ◽

Argon Plasma Coagulation ◽

Argon Plasma ◽

High Recurrence Rate ◽

Gastric Antral Vascular Ectasia ◽

Success Rates ◽

Recurrence Rates ◽

Vascular Ectasia ◽

Major Treatment

Gastric antral vascular ectasia (GAVE) is one of the uncommon causes of upper gastrointestinal bleeding. Major treatment of GAVE includes pharmacotherapy, endoscopy, and surgery. The efficacy and safety of pharmacotherapy have not been sufficiently confirmed; and surgery is just considered when conservative treatment is ineffective. By comparison, endoscopy is a common treatment option for GAVE. This paper reviews the currently used endoscopic approaches for GAVE, mainly including argon plasma coagulation (APC), radiofrequency ablation (RFA), and endoscopic band ligation (EBL). It also summarizes their efficacy and procedure-related adverse events. The endoscopic success rate of APC is 40–100%; however, APC needs several treatment sessions, with a high recurrence rate of 10–78.9%. The endoscopic success rates of RFA and EBL are 90–100% and 77.8–100%, respectively; and their recurrence rates are 21.4–33.3% and 8.3–48.1%, respectively. Hyperplastic gastric polyps and sepsis are major adverse events of APC and RFA; and Mallory–Weiss syndrome is occasionally observed after APC. Adverse events of EBL are rare and mild, such as nausea, vomiting, esophageal or abdominal pain, and hyperplastic polyps. APC is often considered as the first-line choice of endoscopic treatment for GAVE. RFA and EBL have been increasingly used as alternatives in patients with refractory GAVE. A high recurrence of GAVE after endoscopic treatment should be fully recognized and cautiously managed by follow-up endoscopy. In future, a head-to-head comparison of different endoscopic approaches for GAVE is warranted.

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Watermelon stomach: clinical aspects and treatment with argon plasma coagulation

Arquivos de Gastroenterologia ◽

10.1590/s0004-28032006000300007 ◽

2006 ◽

Vol 43 (3) ◽

pp. 191-195 ◽

Cited By ~ 19

Author(s):

Dalton M. Chaves ◽

Paulo Sakai ◽

Cláudio V. Oliveira ◽

Spencer Cheng ◽

Shinichi Ishioka

Keyword(s):

Liver Disease ◽

Endoscopic Treatment ◽

Argon Plasma Coagulation ◽

Argon Plasma ◽

Gastric Antral Vascular Ectasia ◽

Plasma Coagulation ◽

Vascular Ectasia ◽

Group 2 ◽

Group 1

BACKGROUND: Gastric antral vascular ectasia is a disorder whose pathogenetic mechanism is unknown. The endoscopic treatment with argon plasma coagulation has been considered one of the best endoscopic therapeutic options. AIM: To analyze the endoscopic and clinical features of gastric antral vascular ectasia and its response to the argon plasma coagulation treatment. PATIENTS AND METHODS: Eighteen patients were studied and classified into two groups: group 1 - whose endoscopic aspect was striped (watermelon) or of the diffuse confluent type; group 2 - diffuse spotty nonconfluent endoscopic aspect. RESULTS: Group 1 with eight patients, all having autoimmune antibodies, but one, whose antibodies were not searched for. Three were cirrhotic and three had hypothyroidism. All had gastric mucosa atrophy. In group 2, with 10 patients, all had non-immune liver disease, with platelet levels below 90.000. Ten patients were submitted to argon plasma coagulation treatment, with 2 to 36 months of follow-up. Lesions recurred in all patients who remained in the follow-up program and one did not respond to treatment for acute bleeding control. CONCLUSION: There seem to be two distinct groups of patients with gastric antral vascular ectasia: one related to immunologic disorders and other to non-immune chronic liver disease and low platelets. The endoscopic treatment using argon plasma coagulation had a high recurrence in the long-term evaluation.

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Histologic and Endoscopic Similarity between Nodular Gastric Antral Vascular Ectasia and Gastric Hyperplastic Polyps Potentially Causing Treatment Delays

Case Reports in Medicine ◽

10.1155/2019/1342368 ◽

2019 ◽

Vol 2019 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Pujitha Kudaravalli ◽

Sheikh A. Saleem ◽

Rachana Mandru ◽

Sekou Rawlins

Keyword(s):

Targeted Therapy ◽

Coronary Artery ◽

Argon Plasma Coagulation ◽

Argon Plasma ◽

Clinical Suspicion ◽

Gastric Antral Vascular Ectasia ◽

Hyperplastic Polyps ◽

Plasma Coagulation ◽

Vascular Ectasia ◽

Upper Gi

Introduction. Gastric antral vascular ectasia (GAVE) is the underlying cause for 4% of nonvariceal upper GI bleeding. Nodular GAVE and gastric hyperplastic polyps have similar appearance on upper GI endoscopy (EGD) as well as histology, which could delay specific targeted therapy. We herein, through this case, would like to highlight that high clinical suspicion is required to diagnose nodular GAVE. Case Report. A 70-year-old male with a past medical history significant for coronary artery disease s/p drug-eluting stent placement on Plavix, coronary artery bypass grafting, mechanical aortic valve replacement on warfarin, and iron deficiency anemia on replacement was admitted for the evaluation of fatigue and melena for a month. Physical examination was positive for black stool. The only significant lab was a drop in hemoglobin/hematocrit (Hg/dl/H%) of 10/32 to 4/12.5. Fibrosure was sought which suggested that the patient had an F4 cirrhosis. Endoscopy showed nodules in the gastric antrum which were presumptively treated as GAVE with argon plasma coagulation (APC). Surgical pathology showed reactive gastropathy and gastric polyps. Review of the past histology suggested that because of the overlap in the histopathological features of hyperplastic polyps and GAVE, they were misinterpreted as hyperplastic polyp rather than nodular GAVE. Discussion. GAVE can be classified endoscopically as punctate, striped, nodular, or polypoidal form. The light microscopic findings considered specific to GAVE are vascular hyperplasia, mucosal vascular ectasia, intravascular fibrin thrombi, and fibromuscular hyperplasia. However, these findings do not differentiate GAVE from hyperplastic gastric polyp. The first line of treatment for GAVE is endoscopic ablation with Nd:YAG laser or argon plasma coagulation. Response to therapy was seen with a mean of 2.6 treatment sessions. There is not a lot of evidence supportive of pharmacological treatment of GAVE with estrogen-progesterone, tranexamic acid, and thalidomide. Serial endoscopic band ligation as well as detachable snares in the management of nodular GAVE refractory to argon plasma coagulation has also been tried. Conclusion. Oftentimes, there is a delay in the diagnosis and treatment of nodular GAVE as the histopathological appearance could be similar to gastric polyps. The diagnosis of GAVE especially nodular GAVE requires a high level of clinical suspicion. Misdiagnosis of nodular GAVE can delay targeted therapy and have fatal outcomes.

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

Journal of Digestive Diseases ◽

10.1111/1751-2980.12958 ◽

2020 ◽

Vol 22 (1) ◽

pp. 23-30

Author(s):

Anna Fábián ◽

Renáta Bor ◽

Ella Szabó ◽

Viktor Kardos ◽

Anita Bálint ◽

...

Keyword(s):

Endoscopic Treatment ◽

Argon Plasma Coagulation ◽

Real Life ◽

Argon Plasma ◽

Gastric Antral Vascular Ectasia ◽

Band Ligation ◽

Plasma Coagulation ◽

Vascular Ectasia ◽

Endoscopic Band Ligation

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Gastric Antral Vascular Ectasia (GAVE) Associated with Systemic Sclerosis: Relapse after Endoscopic Treatment by Argon Plasma Coagulation

Internal Medicine ◽

10.2169/internalmedicine.46.6203 ◽

2007 ◽

Vol 46 (6) ◽

pp. 279-283 ◽

Cited By ~ 22

Author(s):

Goro Shibukawa ◽

Atsushi Irisawa ◽

Natsumi Sakamoto ◽

Tadayuki Takagi ◽

Takeru Wakatsuki ◽

...

Keyword(s):

Systemic Sclerosis ◽

Endoscopic Treatment ◽

Argon Plasma Coagulation ◽

Argon Plasma ◽

Gastric Antral Vascular Ectasia ◽

Plasma Coagulation ◽

Vascular Ectasia

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Endoscopic mucosal resection for recurrent gastric antral vascular ectasia

VASA ◽

10.1024/0301-1526.37.3.289 ◽

2008 ◽

Vol 37 (3) ◽

pp. 289-292 ◽

Cited By ~ 5

Author(s):

Katsinelos ◽

Chatzimavroudis ◽

Katsinelos ◽

Panagiotopoulou ◽

Kotakidou ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

Argon Plasma Coagulation ◽

Argon Plasma ◽

Deficiency Anemia ◽

Gastric Antral Vascular Ectasia ◽

Therapeutic Approaches ◽

Plasma Coagulation ◽

Vascular Ectasia ◽

Mucosal Resection ◽

First Case

Gastric antral vascular ectasia (GAVE) is an overt or occult source of gastrointestinal bleeding. Despite several therapeutic approaches have been successfully tested for preventing chronic bleeding, some patients present recurrence of GAVE lesions. To the best of our knowledge, we report the first case, of a 86-year-old woman who presented severe iron-deficiency anemia due to GAVE and showed recurrence of GAVE lesion despite the intensive argon plasma coagulation treatment. We performed endoscopic mucosal resection of bleeding GAVE with resolution of anemia.

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