Endoscopic YAG laser treatment of watermelon stomach (gastric antral vascular ectasia) in patients with systemic sclerosis

OBJECTIVE: Gastric antral vascular ectasia (GAVE) has been recognized as a rare but important cause of chronic iron deficiency anemia. A number of reported patients were found to have evidence of autoimmune disorders or connective tissue diseases. We carried out this study in order to determine the clinical, endoscopic, and pathologic features in a large series of patients with systemic sclerosis (SSc) who were diagnosed with GAVE. We also determined the response to YAG laser treatment for chronic blood loss in these patients. METHODS: A retrospective chart review of 20 cases diagnosed over an 11-year period, with diagnoses of both SSc and GAVE. RESULTS: Twenty patients with SSc presented with prominent anemia and were diagnosed with GAVE. Treatment with endoscopic laser therapy was successful in preventing surgery for bleeding in GAVE in 85% of cases. CONCLUSIONS: GAVE should be considered in patients with SSc who develop chronic iron deficiency anemia. YAG laser treatment can be useful in the treatment of chronic blood loss anemia in SSc patients with GAVE.     

Treatment of chronic bleeding from gastric antral vascular ectasia (GAVE) with estrogen-progesterone in cirrhotic patients: an open pilot study

OBJECTIVE: Gastric antral vascular ectasia (GAVE) is a rare cause of chronic bleeding in cirrhotic patients. Treatment of GAVE with surgical or nonsurgical portal decompression, beta-blockers, or endoscopic therapy provides disappointing results. In the present study, we evaluated the efficacy of estrogen-progesterone therapy, which has been reported to control chronic bleeding in gastrointestinal vascular malformations, such as Osler-Weber Rendu disease or angiodysplasia, in GAVE-related chronic bleeding. METHODS: Six cirrhotic patients who bled chronically from GAVE were included. Three had alcoholic cirrhosis, two cryptogenic cirrhosis, and one primary biliary cirrhosis. Grade 1 esophageal varices were noted in four patients. Bleeding could not be controlled by beta-blockers, and endoscopic therapy was not considered given the extension of the antral vascular lesions. RESULTS: Before the start of therapy, transfusion requirements averaged 3.5 units/month over a 1.5-11 month period of observation. Patients were then treated with a combination of ethynil estradiol 30 microg and noretisterone 1.5 mg daily. During follow-up (range 3-12 months), bleeding did not recur in four patients; in one patient, treatment with estrogen progesterone decreased the need for transfusions from 4 units/month to 1.4 unit/month; this patient stopped the treatment inadvertently after 6 months and severe anemia recurred with a need for 4 units of blood in the following month; reintroduction of the treatment resulted in an increase of hemoglobin levels without the need for blood transfusions during the following 4 months. In the last patient, a 5-month treatment did not improve chronic bleeding. CONCLUSIONS: The present study suggests that estrogen-progesterone therapy is useful in the treatment of chronic bleeding related to GAVE; however, these findings require confirmation by a controlled trial.     

Clinical features and treatment of hematopoietic stem cell transplantation-associated gastric antral vascular ectasia

Gastric antral vascular ectasia (GAVE) may occur after hematopoietic stem cell transplantation (HSCT) and cause severe and prolonged gastric bleeding. The underlying pathology of transplant-associated GAVE (HSCT-GAVE) is poorly understood and an effective therapeutic strategy has not been established yet. We retrospectively reviewed the medical records of 230 consecutive allogeneic transplant recipients in our institution between January 1997 and June 2002. We identified five patients who developed HSCT-GAVE (2.2%). Four patients had bleeding from HSCT-GAVE and one patient had HSCT-GAVE discovered incidentally. The clinical features of these patients were similar in that they all received conditioning treatment with busulfan and had history of thrombotic microangiopathy. Furthermore, treatment with a beta-blocker apparently improved the outcome of HSCT-GAVE in three patients.     

Gastric antral vascular ectasia (watermelon stomach) in patients with systemic sclerosis

This report describes 5 patients with systemic sclerosis (SSc) who developed severe, recurrent upper gastrointestinal (GI) bleeding due to gastric antral vascular ectasia (GAVE). The clinical records, the endoscopic findings, and the histologic appearance of biopsy specimens and surgically resected gastric tissue from the patients were reviewed. All 5 patients developed severe and recurrent episodes of upper GI bleeding leading to severe anemia requiring multiple transfusions. The cutaneous involvement was diffuse in 3 patients and limited in 2. All but 1 had cutaneous telangiectasias. The diagnosis of GAVE was established by endoscopy within 3 years of the diagnosis of SSc in all cases. One patient required heater probe cautery, 2 required laser coagulation, and 2 underwent surgical resection of the gastric antrum for control of the GI bleeding. The possibility of GAVE should be considered in SSc patients who have recurrent upper GI bleeding. It is suggested that the antral vascular lesions in these patients may represent a component of the spectrum of vascular alterations of SSc.     

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

Background and study aimsGastric 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 methodsTwenty-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 1 month after the therapeutic procedure to ensure complete ablation of all lesions.ResultsThe documented Hb levels and number of blood units transfused 3 months after APC were recorded. At endoscopy, all patients had the classic type of GAVE. The mean Hb level increased from 7.5 ± 1.7 g dl^?1 before APC to 10.2 ± 0.8 g dl^?1 after APC (p value <0.001). The transfusion requirements significantly decreased to 0.2 ± 0.5 units/patient (p value <0.001).ConclusionEndoscopic APC is a safe, effective and inexpensive modality in treating GAVE and could be an alternative to the currently available endoscopic methods.     

The clinical and endoscopic spectrum of the watermelon stomach.

The watermelon stomach is an uncommon but treatable cause of chronic gastrointestinal bleeding. We report our experience with the clinical and endoscopic features of 45 consecutive patients treated by endoscopic Nd:YAG laser coagulation. The prototypic patient was a woman (71%) with an average age of 73 years (range of 53-89 years) who presented with occult (89%) transfusion-dependent (62%) gastrointestinal bleeding over a median period of 2 years (range of 1 month to > 20 years). Autoimmune connective tissue disorders were present in 28 patients (62%), especially Raynaud's phenomena (31%) and sclerodactyly (20%). Atrophic gastritis occurred in 19 of 19 (100%) patients, with hypergastrinemia in 25 (76%) of 33 patients tested. Antral endoscopic appearances included raised or flat stripes of ectatic vascular tissue (89%) or diffusely scattered lesions (11%). Proximal gastric involvement was present in 12 patients (27%), typically in the presence of a diaphragmatic hernia. Endoscopic laser therapy after a median of one treatment (range of 1-4) resulted in complete resolution of visible disease in four patients (13%) and resolution of > 90% in 24 patients (80%). Hemoglobin levels normalized in 87% of patients over a median follow-up period of 2 years (range of 1 month to 6 years) with no major complications. Blood transfusions were not necessary after laser therapy in 86% of 28 initially transfusion-dependent patients. The characteristic clinical, laboratory, and endoscopic features allow for a confident diagnosis that can lead to successful endoscopic treatment.     

Efficacy and safety of Nd. YAG laser for the treatment of bleeding from radiation proctocolitis

BACKGROUND: Bleeding due to radiation proctocolitis is a frequent and severe complication of radiotherapy in cancers of the pelvis. AIM: The aim of this study was to evaluate the efficacy and safety of endoscopic treatment with Nd:YAG laser in this condition. PATIENTS AND METHODS: A series of 9 patients with radiation-induced damage in the rectum and sigma were treated with endoscopic Nd:YAG laser until significant bleeding stopped and endoscopic features of proctocolitis improved. They received a median of 3 laser treatments (range 1-10) over a maximum time period of 11 months. RESULTS: In 4 cases, bleeding ceased and, in 4, it was reduced to occasional spotting. In the remaining patient, laser therapy led to only a transient improvement, but did not modify the requirement of blood transfusion. In the 5 patients also suffering from urgency, incontinence and/or rectal mucoid discharge, the laser therapy course also relieved these symptoms. No significant treatment-related complications were observed. CONCLUSIONS: Endoscopic Nd: YAG laser is a useful and safe treatment for patients with bleeding due to radiation proctocolitis.     

Endoscopic resolution and recurrence of gastric antral vascular ectasia after serial treatment with argon plasma coagulation

AIM To evaluate long-term endoscopic resolution and recurrence rate of gastric antral vascular ectasia(GAVE) after argon plasma coagulation(APC) treatment.METHODS This was an IRB-approved retrospective single center study that included patients endoscopically treated for GAVE between 1/1/2008 to 12/31/2014. The primary and secondary end points of the study were rate of endoscopic resolution of GAVE after APC treatment and recurrence rate of GAVE after endoscopic resolution, respectively. Endoscopic resolution of GAVE was defined as no endoscopic evidence of GAVE after treatment with APC. Recurrence of GAVE was defined as endoscopic reappearance of GAVE after prior resolution.RESULTS Twenty patients met the study criteria. Median age(range) of the patients was 59.5 years(42-74 years). GAVE was associated with underlying cirrhosis in 16(80%) patients. Indications for initial esophagogastroduodenoscopy(EGD) included hematemesis and/or melena(9/20, 45%), iron deficiency anemia(6/20, 30%), screening or surveillance of varices(4/20, 20%), and occult gastrointestinal bleeding(1/20, 5%). The patients were treated with a total of 55 APC sessions(range 1-7 sessions). Successful endoscopic resolution of GAVE wasachieved in 8 out of 20 patients(40%). There was no correlation between number of treatment sessions and GAVE treatment success(P = NS). Recurrence of GAVE was noted on a subsequent EGD in 2 out of 8 patients(25%) with prior endoscopic resolution of GAVE. Median follow-up period for the study population was 627 d(range 63-1953 d).CONCLUSION Endoscopic resolution rate of GAVE was low(40%) with a 25% recurrence rate after treatment with APC. These rates suggest that APC treatment of GAVE may not be optimal in many circumstances.     

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.     

ENDOSCOPIC COAGULATION THERAPY IS USEFUL FOR IMPROVING ENCEPHALOPATHY IN CIRRHOTIC PATIENTS WITH GASTRIC ANTRAL VASCULAR ECTASIA

Background: Gastric antral vascular ectasia (GAVE) is an uncommon but treatable cause of chronic gastrointestinal bleeding often associated with severe cirrhosis. Efficacy of endoscopic treatment is well known; however, long‐term outcome after endoscopic treatment is not clear. Methods: We studied 16 cases of GAVE patients with liver cirrhosis that were endoscopically treated using heater probe unit or argon plasma coagulator. Endoscopic finding of GAVE and clinical finding of hepatic encephalopathy in particular was evaluated after endoscopic therapy. Results: After endoscopic ablation therapy, mucosal vascular lesion of GAVE and rebleeding occurred in four patients during follow up; however, re‐treatment was effective and long‐term hemostasis was achieved. Moreover, a case report herein revealed the effectiveness of endoscopic therapy on hepatic encephalopathy of GAVE patients with cirrhosis. In the follow‐up study of 13 patients of GAVE with cirrhosis that suffered from encephalopathy, the coma level of nine patients was improved after endoscopic therapy. Conclusion: Endoscopic treatment, such as heater probe coagulation and argon plasma coagulation therapy, are effective and useful for long‐term follow up. Also, the beneficial effect of endoscopic therapy on hepatic encephalopathy for GAVE with cirrhosis encourages us to find and treat the mucosal lesion intensively to improve the quality of life of such patients.     

Effect of endoscopic treatment of gastric antral vascular extasia associated with chronic liver disease

Background : Gastric antral vascular ectasia (GAVE), as a cause of upper gastrointestinal bleeding, has been treated surgically, endoscopically and pharmacologically for the past 20 years. Methods : We analyzed the clinical effect of endoscopic treatment for 12 cases of GAVE diagnosed at Osaka National Hospital between January 1993 and October 1998. Results : Eight of the 12 cases were treated endoscopically due to marked anemia and histories of gastrointestinal bleeding. All had chronic liver disease (CLD). Mean age was 69 years on diagnosis. Male to female ratio was 1 : 1. Gastric antral vascular ectasia was a cause of 3.9% of bleeding associated with CLD. The modes of endoscopic treatment of the eight cases were laser photocoagulation (1), electrocautery (3), and heater probe thermocoagulation (4). The initial treatment required an average of 5.1 sessions over a period of 43 days. Initial hemostasis was successful in all cases. Treatments for recurrent bleeding were necessary in six cases within 9.2 months, and endoscopic coagulation was again effective in two cases. Corticosteroids were effective in two of three cases resistant to endoscopic therapy. Mean follow‐up period after initial treatment was 2.8 years. The mean total number of therapeutic endoscopy sessions was 9.6. Conclusion : Endoscopic treatments and/or corticosteroids have yielded sufficient results in the hemorrhage of GAVE. Factors affecting the recurrence of GAVE need to be analyzed in CLD patients.     

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.     

The natural history of portal hypertensive gastropathy: influence of variceal eradication

OBJECTIVE: The natural history and likelihood of bleeding from portal hypertensive gastropathy (PHG) present in patients with portal hypertension before endoscopic variceal obliteration may differ from that in patients who develop PHG during or after variceal eradication. METHODS: A total of 967 variceal bleeders who had achieved variceal eradication by endoscopic sclerotherapy in the recent past were prospectively studied. In all, 88 (9.1%) patients (cirrhosis in 54, noncirrhotic portal fibrosis in 18, and extrahepatic portal vein obstruction in 16) had distinct mucosal lesions. PHG alone was present in 78, PHG with gastric antral vascular ectasia (GAVE) in eight, and GAVE alone in two patients. PHG was graded as mild or severe and according to whether present before (group A) or after endoscopic intervention (group B). Patients underwent regular endoscopy at follow-up to see if the PHG was transitory (disappearing within 3 months), persistent (no change), or progressive. Bleeding from PHG lesions was defined as acute or chronic. RESULTS: Twenty-two (26%) patients had PHG before (group A) and 64 (74%) developed PHG after variceal eradication (group B). During a mean follow-up of 25.1 +/- 14.2 months, PHG lesions disappeared in group A in only two patients (9%), but in group B in 28 (44%) patients (p < 0.05). PHG lesions more often progressed in the former as compared to the latter (18% vs 9.4%, p = NS). The incidence of bleeding was higher in group A than group B (32% vs 4.7%, p < 0.02). Bleeding from PHG occurred in 10 patients (11.6%); seven of them were from group A, and all had either progressive (n = 3) or persistent (n = 4) lesions. CONCLUSIONS: PHG developing after variceal eradication is often transitory and less severe. If PHG is pre-existing, endoscopic therapy for varices could worsen the PHG, with a likelihood of bleeding. Such patients may be benefited by concomitant beta-blocker therapy.     

Endoscopic band ligation versus argon plasma coagulation for gastric antral vascular ectasia associated with liver diseases

Aim: The aim of the present study was to evaluate the clinicopathological features and the efficacy of endoscopic treatments in treating gastric antral vascular ectasia (GAVE) in association with liver diseases. Methods: Thirty‐four patients with the characteristic endoscopic findings of GAVE were enrolled. Endoscopic treatments were carried out for all 34 patients, including argon plasma coagulation (APC) in 22 patients and endoscopic band ligation (EBL) in 12 patients. Results: All 34 patients had iron‐deficiency anemia and 21 patients also had a history of tarry stools. The underlying pathologies of chronic liver diseases were liver cirrhosis in 26 patients, liver cirrhosis associated with hepatocellular carcinoma in six, and idiopathic portal hypertension in two. The liver function was classified by Child–Pugh classification: class A (n = 6), class B (n = 21), and class C (n = 7). Antral motility was frequent and intense in all 34 GAVE patients. In the 22 patients who received APC, endoscopies revealed the recurrence of GAVE in 15 patients requiring further treatment by APC (recurrence rate, 68.2%). Seven patients died during the follow‐up period, including two cases with bleeding‐related deaths. In the 12 patients who received EBL, endoscopies revealed the recurrence of GAVE in one patient requiring further treatment by EBL (recurrence rate, 8.3%). Two patients died during the follow‐up period, neither were bleeding‐related deaths. Conclusions: The results suggest that GAVE is related to severe liver damage and portal hypertension. APC has a high recurrence rate of GAVE in the medium term after treatment. EBL may be useful as a treatment for GAVE.     

Histological estimation of the efficacy of endoscopic laser coagulation therapy for diffuse antral vascular ectasia

We present the case of a 72-year-old woman with successful control of repeated episodes of bleeding from diffuse antral vascular ectasia (DAVE) by laser coagulation therapy. In addition to DAVE, the patient also suffered from severe iron deficiency anaemia (due to recurrent bleeding), liver cirrhosis, and huge tumours of hepatocellular carcinoma (HCC). She was referred from another hospital after failure to stop her bleeding episodes. Endoscopic examination revealed diffuse speckled telangiectasia over most of the stomach (from antrum to the upper portion of the body) and large numbers of blood clots. The patient had received repeated blood transfusions, haemostatic drugs, and H2 receptor antagonists at the other hospital, without improvement of the repeated bleeding. She underwent three sessions of endoscopic laser coagulation therapy for the lesions at our hospital after the final diagnosis of DAVE had been made based on the characteristic histological findings of biopsied specimens. This treatment improved her general condition and stopped the bleeding from the gastrointestinal tract even without fasting. Unfortunately, however, her liver function gradually worsened due to HCC and previous massive bleeding, and she finally died of liver failure three months after the last laser session. Autopsied specimens obtained from the patient's stomach revealed that macroscopic diffuse speckled telangiectasia and microscopic typical vasodilatation in mucosal and submucosal layers of gastric tissue had disappeared in the treated areas but not all portions of the DAVE lesion. These histological findings for the treated areas, in addition to the clinical improvement of bleeding, suggest that endoscopic laser coagulation therapy may be useful and one of the first choices in treatment for DAVE.     

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

BACKGROUNDAccurate 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).AIMTo determine the added diagnostic value of virtual chromoendoscopy to high definition white light for real-time endoscopic diagnosis of GAVE and PHG.METHODSWe 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.RESULTSTwenty-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.CONCLUSIONThis 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.     

Endoscopic Nd:YAG laser treatment of severe radiation injury of the lower gastrointestinal tract: long-term follow-up

We report a series of patients with severe radiation injury treated with endoscopic laser photocoagulation. Eight patients with recurrent lower gastrointestinal bleeding secondary to procosigmoiditis were treated with endoscopic Nd:YAG laser therapy. Patients were followed for an average of 21.7 months after the first laser treatment. Average transfusion requirements and hospital admissions per patient-month were 0.93 and 0.27, respectively, in the prelaser period and 0.18 and 0.06, respectively, in the entire period following the first laser treatment. A total of 26 laser treatments were performed. There were three major (prolonged ileus) and one minor (pain) complication. We conclude that endoscopic Nd:YAG laser photocoagulation is a safe, effective, and lasting treatment in severe, symptomatic radiation injury of the lower gastrointestinal tract.     

Prospective comparison of contact with noncontact Nd:Yag laser therapy for palliation of esophageal carcinoma

Twenty patients with dysphagia due to inoperable esophageal cancer were randomized to receive either contact or noncontact endoscopic laser treatment. Treatment groups were similar with respect to age, dysphagia score, and tumor dimensions. The median number of initial treatment sessions was two in both groups, and the median treatment times per session were 23 min (range, 12 to 55 min) in the contact group and 19 min (range, 5 to 28 min) in the noncontact group. Median dysphagia scores were also similar in both groups 1 month after laser treatment, and no difference was apparent in the duration of palliation. There were no patient complications attributable to laser therapy, but damage to the laser wave guide occurred in three contact sessions and two noncontact sessions. These data suggest no advantage for the contact method of endoscopic Nd:YAG laser palliation of esophageal carcinoma with respect to number of treatment sessions, relief of dysphagia, or occurrence of complications.     

Efficacy of argon plasma coagulation for gastric antral vascular ectasia associated with chronic liver disease.

Gastric antral vascular ectasia (GAVE) is a rare cause of chronic gastrointestinal bleeding. The aim of this study was to evaluate the relationship between GAVE with cirrhotic patients and liver dysfunction, portal hypertension and the safety and efficacy of argon plasma coagulation (APC) in treating GAVE with cirrhotic patients. Eight cirrhotic patients with the characteristic endoscopic findings of GAVE were registered. In this study, APC was performed for GAVE in all eight patients. The patients-liver function was classified by Child-Pugh classification and classifications were: two class A, five class B and one class C (mean score: 7.8). Five patients had previously received prophylactic endoscopic injection sclerotherapy for esophageal varices and one had esophageal varices. Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices had been performed in other one patient. Portal hypertensive gastropathy (PHG) was recognized in only one case. APC was performed in all eight patients and one to three treatment sessions were needed (mean: 1.8 sessions). No complications were observed in the initial treatment. During follow-up, endoscopies revealed the recurrence of GAVE in two patients requiring further treatment by APC (recurrence rate: 25%). After APC treatment, the recurrence of GAVE was not observed with endoscopy in the other six patients. The results suggest that GAVE is related to severe liver damage and portal hypertension in cirrhotic patients. APC is a safe and effective treatment against GAVE.     

Endoscopic Nd:YAG Laser Coagulation as Palliative Therapy for Obstructing Esophageal Carcinoma

Fifteen consecutive patients who underwent endoscopic Nd:YAG laser therapy for palliation of advanced esophageal carcinoma were treated between December 1, 1983 and April 15, 1985. All but three had recurrent or persistent symptomatic disease after prior treatment with other modalities. Tumor cell type was squamous cell carcinoma in eight patients and adenocarcinoma in seven. Tumor location was distal in seven, middle in four, and upper esophagus in four. Mean tumor length was 5.6 cm and mean initial luminal diameter 2.5 mm. Twelve of 15 patients had virtually complete luminal occlusion before laser therapy. Treatment was completed in a mean of 3.47 sessions (range 2.7) over a mean of 9.18 days (range 1-18). An average of 2490 joules was delivered per session. An average of 11,695 joules was required to achieve the treatment objective of passage of a 10-mm endoscope. Mean posttreatment luminal diameter was 11.9 mm, and all but two patients noted considerable improvement in swallowing. Two patients were successfully retreated an average of 8 wk after initial laser therapy for recurrent obstruction. Two patients developed bronchoesophageal fistulae an average of 4 wk after treatment and both were successfully managed with endoscopic insertion of an esophageal prosthesis. Nd:YAG laser therapy appears to be a relatively safe and well-tolerated method to rapidly relieve luminal obstruction in patients with advanced esophageal carcinoma.