Gastric antral vascular ectasia in cirrhotic patients: absence of relation with portal hypertension.
BACKGROUND: Portal hypertensive gastropathy and gastric antral vascular ectasia (GAVE) are increasingly recognised as separate entities. The pathogenic role of portal hypertension for the development of GAVE is still controversial. AIMS: To evaluate the effects of portal decompression on chronic bleeding related to GAVE in cirrhotic patients. METHODS: Eight patients with cirrhosis and chronic blood loss related to GAVE were included. GAVE was defined endoscopically and histologically. RESULTS: All patients had severe portal hypertension (mean portocaval gradient (PCG) 26 mm Hg) and chronic low grade bleeding. Seven patients underwent transjugular intrahepatic portosystemic shunt (TIPS) and one had an end to side portacaval shunt. Rebleeding occurred in seven patients. In these, TIPS was found to be occluded after 15 days in one patient; in the other six, the shunt was patent and the PCG was below 12 mm Hg in five. In the responder, PCG was 16 mm Hg. Antrectomy was performed in four non-responders; surgery was uneventful, and they did not rebleed after surgery, but two died 11 and 30 days postoperatively from multiorgan failure. In one patient, TIPS did not control GAVE related bleeding despite a notable decrease in PCG. This patient underwent liver transplantation 14 months after TIPS; two months after transplantation, bleeding had stopped and the endoscopic appearance of the antrum had normalised. CONCLUSIONS: Results suggest that GAVE is not directly related to portal hypertension, but is influenced by the presence of liver dysfunction. Antrectomy is a therapeutic option when chronic bleeding becomes a significant problem but carries a risk of postoperative mortality. (+info)
The efficacy of octreotide therapy in chronic bleeding due to vascular abnormalities of the gastrointestinal tract.
BACKGROUND: The treatment of angiodysplasia and watermelon stomach, vascular abnormalities implicated in gastrointestinal bleeding of obscure origin, is a major clinical problem. AIM: To determine the efficacy of octreotide in patients with long-standing gastrointestinal bleeding due to acquired angiodysplasia and watermelon stomach, resistant to previous treatments and not suitable for surgery because of old age and/or concomitant disorders. PATIENTS AND METHODS: We treated 17 patients (seven had isolated angiodysplasia, seven had multiple upper and lower gastrointestinal angiodysplasia, and three had watermelon stomach) with octreotide (0. 1 mg subcutaneous t.d.s. for 6 months). Six of the patients had liver cirrhosis, one had Glanzmann-type platelet derangement, two had cardiovascular diseases and one had chronic uraemia. RESULTS: Octreotide treatment stopped bleeding in 10 patients. A transient improvement was observed in four, who needed subsequent cyclical retreatment to correct low haemoglobin levels. No effect was observed in three, probably due to the severity of the concomitant disorders. CONCLUSIONS: Octreotide is a safe drug that may be useful to control the recurrent gastrointestinal bleeding due to acquired angiodysplasia and watermelon stomach, especially in patients who are not candidates for surgery due to old age and/or concomitant disorders. (+info)
Gastric antral vascular ectasia in systemic sclerosis: complete resolution with methylprednisolone and cyclophosphamide.
A case of severe, transfusion dependent anaemia in a 72 year old woman, which on endoscopy was found to be due to gastric antral vascular ectasia (GAVE), is reported. Repeated endoscopic sclerotherapy was ineffective. She subsequently developed Raynaud's phenomenon and on further investigation was found to have classical systemic sclerosis with lung involvement. Treatment with pulses of intravenous methylprednisolone and cyclophosphamide resulted in significant improvement in her pulmonary function tests and skin score. Coincidentally, her haemoglobin stabilised and further endoscopic examinations were normal. This is the first report of cyclophosphamide and methylprednisolone leading to complete and sustained resolution of GAVE in association with systemic sclerosis. (+info)
Cure of gastric antral vascular ectasia by liver transplantation despite persistent portal hypertension: a clue for pathogenesis.
Gastric antral vascular ectasia (GAVE) is a rare cause of chronic bleeding in cirrhotic patients. It has been suggested that these gastric lesions might be related to portal hypertension, hepatic insufficiency, or both parameters. We report two cases of cirrhotic patients in whom GAVE was the source of recurrent bleeding. These patients also had complete portal vein thrombosis. Liver transplantation was performed and an end-to-end cavoportal anastomosis was performed, leaving patients with persistent portal hypertension after surgery. We observed complete disappearance of the antral lesions several weeks after transplantation, which shows that the GAVE is not related to portal hypertension but is rather a direct consequence of liver failure. Possible pathophysiologic mechanisms are discussed. (+info)
Review article: current therapeutic options for gastric antral vascular ectasia.
Gastric antral vascular ectasia, or 'watermelon stomach', is a rare but important cause of gastrointestinal blood loss and anaemia, which has characteristic endoscopic and histological features. The pathogenesis of this condition remains unclear; however, many associated disorders have been documented. Various medical, surgical and endoscopic therapeutic modalities have been attempted with variable success. Leading contenders for the therapeutic modality of choice include hormonal therapy, endoscopic Nd:YAG laser and argon plasma coagulation. Randomized controlled trials to identify the ideal treatment method are lacking at present. (+info)
Watermelon stomach: clinical aspects and treatment with argon plasma coagulation.
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. (+info)
Does capsule endoscopy recognise gastric antral vascular ectasia more frequently than conventional endoscopy?
BACKGROUND: Gastric antral vascular ectasia (GAVE) is a rare cause of obscure gastrointestinal bleeding which can be difficult to recognise endoscopically. Capsule endoscopy is primarily designed to image the small bowel, but may identify gastric and colonic lesions. There have been few reported cases of GAVE diagnosed by capsule endoscopy in the literature. OBJECTIVE: Our aim was to assess the frequency of GAVE in patients with obscure gastrointestinal bleeding referred for capsule endoscopy. DESIGN: Case series. SETTING: This study was conducted in a tertiary referral hospital. PATIENTS. This study comprised 128 consecutive patients with obscure gastrointestinal bleeding. INTERVENTIONS: All patients underwent capsule endoscopy. RESULTS. Six patients were diagnosed with GAVE on the basis of the capsule endoscopy findings (4.7%, five female, median age 71.5 years). All patients had previously had numerous gastrointestinal investigations prior to capsule endoscopy. Five patients to date have been treated with argon plasma coagulation of their vascular lesions. This has resulted in stabilisation of their haemoglobin and cessation of blood transfusions in 4/5 cases with an average follow up period of 15 months. CONCLUSIONS: GAVE is commonly missed at gastroscopy and accounted for 4.7% of patients referred for capsule endoscopy with obscure gastrointestinal bleeding (in our series). This case series represents the largest number of GAVE recognised by capsule endoscopy. In the presence of any of the reported risk/associated factors for GAVE the gastroenterologist interpreting the capsule images should have a high index of suspicion. (+info)
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. (+info)