Endoscopic therapy for upper-GI vascular ectasias

BACKGROUND: Upper-GI vascular ectasias, including angiodysplasia and gastric antral vascular ectasia may present with either acute or chronic bleeding. Endoscopic thermal modalities have been used to control acute bleeding and reduce transfusion requirements. METHODS: Endoscopic experience was reviewed for a 6-year period during which 32 patients requiring blood transfusions for upper-GI angiodysplasia or gastric antral vascular ectasia were evaluated. Patients seen during the first 5 years were treated with either Nd:YAG laser photocoagulation or multipolar electrocoagulation. During the most recent 12 months, all patients were treated by argon plasma coagulation. Response to therapy was assessed by change in mean Hb and transfusion requirements. RESULTS: Overall, 16 patients were treated by laser photoablation alone; 9, argon plasma coagulation with or without laser; and 7, multipolar electrocoagulation with or without laser. Mean follow-up for all patients was 19 months. After therapy, mean Hb concentration rose from 76 to 114 g/L for patients with gastric antral vascular ectasia and from 85 to 118 g/L for those with angiodysplasia. Endoscopic therapy abolished or reduced transfusion requirements in 93% of patients with gastric antral vascular ectasia and 76% with angiodysplasia. Patients with gastric antral vascular ectasia required a mean of 6 treatment sessions, while those with angiodysplasia required one to two sessions. CONCLUSIONS: Endoscopic thermal ablation effectively controls acute bleeding and reduces transfusion requirements in most patients with upper-GI vascular ectasias. Patients with gastric antral vascular ectasia require significantly more treatment sessions to achieve this effect.     

Endoscopic argon plasma coagulation for the treatment of gastric antral vascular ectasia (watermelon stomach): long-term results

INTRODUCTION: Gastric antral vascular ectasia is a rare but well-recognised cause of occult gastrointestinal bleeding. Various endoscopic treatments have been tried in this condition. We report our experience with argon plasma coagulation in the treatment of gastric antral vascular ectasia. PATIENTS AND METHODS: Twelve patients with endoscopically proved gastric antral vascular ectasia were included. All patients received argon plasma coagulation with power of 40 W at a median interval of 4 weeks. The pre-treatment haemoglobin and transfusion requirements were compared with the post-treatment values. RESULTS: There was a sustained increase in mean haemoglobin levels post-treatment. The mean haemoglobin levels pre- and post-treatment were 8.13 +/- 0.70 and 12.2 +/- 0.32 g/dl, respectively (P = 0.008). All patients were anaemic and 58.3% of the patients were transfusion dependent. The mean number of units of blood transfusion in the period 6 months prior to treatment was 11.3 +/- 5.68. Following argon plasma coagulation, the number of transfusions decreased significantly to 1.1 +/- 0.57 units (P = 0.018). No significant procedure-related complications were identified. CONCLUSION: Argon plasma coagulation is a safe and effective alternative to the currently available endoscopic modalities of treatment for gastric antral vascular ectasia.     

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.     

Computed virtual chromoendoscopy - enhanced videocapsule endoscopy is of potential benefit in gastric antral vascular ectasia syndrome refractory to endoscopic treatment

Gastric antral vascular ectasia (GAVE) syndrome represents a rare cause of gastrointestinal bleeding. More extensive small-bowel involvement must be excluded in those patients with GAVE syndrome in whom aggressive endoscopic treatment of antral lesions results in lack of control of digestive bleeding, and for this subset of patients videocapsule endoscopy examination should be considered. However, since the dim angioectatic lesions, even if located in the gastric antrum, might be difficult to accurately outline with standard endoscopy, virtual chromoendoscopy techniques have been employed to aid in their detection, and the presented case illustrates how Fujinon intelligent color-enhancement (FICE) technology implemented in videocapsule endoscopy clearly emphasizes the vascular morphology and delineation of antral angioectasias, allowing better targeted endoscopic treatment and improving patient outcome.     

The Role of Therapeutic Endoscopy in Patients With Cirrhosis-Related Causes of Gastrointestinal Bleeding

Purpose of Review

This article aims to review current therapeutic endoscopic treatments available for the management of gastrointestinal bleeding related to cirrhosis.

Recent Findings

Endoscopic band ligation is an effective treatment for primary prophylaxis, acute bleeding, and secondary prophylaxis of esophageal varices as well as for acute bleeding and secondary prophylaxis of select gastric varices. Sclerotherapy is a treatment option for acute bleeding and secondary prophylaxis of esophageal varices when band ligation is technically difficult. Cyanoacrylate glue injection is an effective treatment for acute bleeding of gastric and ectopic varices. Argon plasma coagulation is first-line and radiofrequency ablation is second-line treatment for chronic bleeding secondary to gastric antral vascular ectasia.

Summary

There are a variety of endoscopic treatment modalities for cirrhosis-related gastrointestinal bleeding, and the appropriate therapy depends on the location of the bleed, history or presence of acute bleeding, and risk factors for intervention-related adverse events.

     

Actualización en hemorragia gastrointestinal de origen no varicoso

This article summarizes the main studies in the field of non-variceal gastrointestinal bleeding reported in the last American Congress of Gastroenterology (Digestive Disease Week) in 2013. Some of these studies have provided new knowledge and expertise in areas of uncertainty. In this context and among other findings, it has been reported that the administration of a proton pump inhibitor (PPI) prior to endoscopy or the early performance of endoscopy–within 6 hours of admission in patients with upper gastrointestinal bleeding (UGIB) (or colonoscopy within 24 hours in patients with lower gastrointestinal bleeding)–does not improve the prognosis of the event. It has also been reported that oral administration of a PPI after endoscopic hemostasis may produce a similar outcome to that of intravenously administered PPI in patients with upper gastrointestinal bleeding (UGIB). In the field of endoscopic therapy, the use of radiofrequency ablation for antral vascular ectasia is of interest. Regarding UGIB and nonsteroidal antiinflammatory drugs (NSAIDs), new data confirm the risk of cardiovascular events by stopping treatment with acetylsalicylic acid (ASA) after an episode of UGIB, the increased risk of UGIB when associating gastrotoxic drugs, and the need to identify both the gastrointestinal and cardiovascular risks of each NSAID and coxib when prescribing these agents. Finally, there is evidence that both environmental and genetic factors are involved in individual susceptibility to gastrointestinal bleeding.     

A novel endoscopic ablation of gastric antral vascular ectasia

An 80-year-old woman was admitted to our hospital because of tarry stool with iron deficiency anemia. Her past history included autoimmune hepatitis. Esophagogastroduodenal endoscopy was performed to investigate the bleeding source and revealed multiple linear gastric vascular malformations in the antrum and cardia, compatible with Gastric antral vascular ectasia (GAVE). Endoscopic ablation was carried out with the tip of the hot biopsy forceps without opening at soft coagulation mode of 80W. The patient tolerated the procedure well and there were no complications associated with endoscopic therapies. After two sessions of endoscopic ablation her anemia improved to around 10 g/dL, an increase of 3.6 g/dL. Various endoscopic treatments have been described to manage GAVE. The most popular is argon plasma coagulation (APC), although APC is associated with over-distension induced by the argon plasma gas. To avoid over-distension and to reduce the abdominal discomfort/pain of this patient, we have used hot biopsy forceps instead of APC. Our case suggests that this procedure is effective, easy and convenient, as no special equipment or skill is necessary.     

Endoscopic follow-up study of development of gastric antral vascular ectasia associated with liver cirrhosis

Gastric antral vascular ectasia is an important cause of chronic gastrointestinal blood loss. However, its development and progression have not yet been clarified. We investigated its early lesions and progression by reviewing endoscopic films of five patients with gastric antral vascular ectasia followed for liver cirrhosis. In all patients, early findings were prepyloric red spots. In two patients, anemia due to gastrointestinal bleeding was already observed when vascular lesions were confined to the distal antrum. In the other three patients, anemia was observed 1–2 years after they showed a diagnostic pattern of gastric antral vascular ectasia. The vascular lesions gradually thickned and extended throughout the antrum, with the complete picture shown in 1.5–5 years. The pattern of distribution was classified into three types: diffuse spotty, diffuse confluent, and striped. These types could be predicted before the complete formation. Gastric antral vascular ectasia associated with liver cirrhosis started as prepyloric red spots and extended to the proximal antrum in various ways and varying time courses of less than 5 years; this entity may cause hemorrhage even in the early stage.     

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.     

ESTROGEN/PROGESTERONE TREATMENT OF DIFFUSE ANTRAL VASCULAR ECTASIA

A case of acute and chronic gastrointestinal bleeding secondary to antral vascular ectasia is presented. The pattern of antral vascular ectasia was the diffuse form. After attempted treatment with endoscopic laser photocoagulation proved ineffective, the bleeding was treated with an estrogen/progesterone combination. The bleeding ceased with this medical therapy. The lesion of antral vascular ectasia persisted, however, despite the cessation of bleeding. Attempted maintenance therapy. consisting of reduction in frequency of estrogen/progesterone therapy to every third day, resulted in resumption of bleeding, requiring reinstitution of daily therapy for control.     

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.     

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.     

Clinical Characterization of Gastric Antral Vascular Ectasia: A Potential Manifestation of the Metabolic Syndrome

Background and ObjectivesGastric antral vascular ectasia is a relatively common endoscopic finding. Past studies have shown an association of gastric antral vascular ectasia with cirrhosis and autoimmune disorders. We aimed to re-examine these associations and to investigate a possible association of gastric antral vascular ectasia with features of the metabolic syndrome.MethodsThere were 135 patients with a diagnosis of gastric antral vascular ectasia from years 1995-2013 seen at the University of Virginia who were identified from a clinical data repository and age and sex matched to a cohort of patients without gastric antral vascular ectasia undergoing endoscopy within the same time frame as the index cases. The groups were compared for comorbidities including autoimmune disease, cirrhosis, vascular disease, body mass index (BMI), diabetes mellitus, and cirrhosis due to nonalcoholic steatohepatitis.ResultsSixty-four percent of gastric antral vascular ectasia patients were cirrhotic, compared with 14% of controls (P <.001). Vascular disease was more common in the gastric antral vascular ectasia cohort (57% vs 36%; P <.001). The mean BMI was also higher in the gastric antral vascular ectasia cohort (33.7 kg/m² vs 28.8 kg/m²; P <.001). Diabetes mellitus and nonalcoholic steatohepatitis cirrhosis were more frequently observed in gastric antral vascular ectasia subjects (64% vs 29% in controls [P <.001] and 28% vs 2% [P <.001], respectively). There was not an increased prevalence of autoimmune disease in gastric antral vascular ectasia patients vs controls (15% vs 13%; P = .861).ConclusionThese results confirm the association of gastric antral vascular ectasia with underlying cirrhosis and revealed a significant correlation of gastric antral vascular ectasia with features of metabolic syndrome such as diabetes, BMI, vascular disease, and nonalcoholic steatohepatitis cirrhosis. The pathophysiology of gastric antral vascular ectasia remains uncertain, but we speculate that it may be a manifestation of the metabolic syndrome.     

Vascular lesions of the gastrointestinal tract

Classification of vascular abnormalities of the gastrointestinal tract on the basis of anatomy and pathophysiology has recently been suggested. Angiodysplasia, an example of an arteriovenous lesion, may cause either acute or chronic bleeding. Diagnosis may be difficult. High-quality standard endoscopy, capsule endoscopy, and double-balloon enteroscopy are most efficacious. Therapy using argon plasma coagulation is currently preferred. Pharmacological therapy has been employed, but a final conclusion about its efficacy cannot yet be drawn. Dieulafoy lesion, an arterial type of vascular abnormality, is rare but serious. It can be responsible for severe haemorrhage. Mechanical endoscopic methods are the most efficacious. Gastric antral vascular ectasia (GAVE), a capillary lesion, can be safely biopsied; it coincides with several diseases (including liver cirrhosis), may cause chronic iron-deficiency anaemia, and is best treated by argon plasma coagulation. Haemangiomas, benign neoplastic lesions, usually occur as part of other specific syndromes; they are difficult to manage due to the multiplicity and size of the lesions.     

VASCULAR ECTASIA OF THE COLON TREATED BY ARGON PLASMA COAGULATION: REPORT OF A CASE

A 72‐year‐old woman presented with hematochezia. Colonoscopy revealed branch‐like vasodilation in the ascending colon and chronic hemorrhage from vascular ectasia of the colon was suspected. Argon plasma coagulation was performed. After treatment, epithelialization of the lesion site was noted and her anemia improved. Vascular ectasia of the colon is recognized as the etiology of lower gastrointestinal bleeding with increasing frequency. Infrared ray electronic endoscopy is useful for determining the extent of disease and argon plasma coagulation, a new hemostatic technique, is suitable for treatment of this condition.     

Successful Endoscopic Treatment of Diffuse Antral Vascular Ectasia and Early Gastric Carcinoma in an Aged Patient

Diffuse antral vascular ectasia and a lla type early gastric cancer were detected in an 83-year-old male patient through an endoscopy during treatment for iron deficiency anemia. Monopolar electrocoagulation was effective for eradication of red spots which represented ectatic vessels. Five sessions of the therapy resulted in the ablation of almost all of the vascular lesions, negative fecal occult blood tests and improvement of his anemia. The lla lesion was endoscopically resected from the posterior wall of the upper body. Histologic examination demonstrated well differentiated adenocarcinoma confined to the mucosal layer. Both the vascular ectasia and carcinoma did not show any sign of recurrence after a year and a half.     

Upper gastrointestinal bleeding from duodenal vascular ectasia in a patient with cirrhosis

We report a cirrhotic patient with duodenal vascular ectasia and spontaneous bleeding. The bleeding was successfully controlled with argon plasma coagulation.Duodenal vascular ectasia may be a cause of upper gastrointestinal bleeding in patients with cirrhosis, and argon plasma coagulation may be effective and safe to achieve hemostasis of this lesion.     

Heat probe treatment for antral vascular ectasia

Antral vascular ectasia ("watermelon stomach") has recently been defined and characterized. This condition may be a source of significant bleeding from the stomach. Although steroids have been useful in some patients, antrectomy has been advocated as definitive therapy. We have treated 12 patients who were bleeding from this lesion with the Olympus HeatProbe Unit and have eliminated further hemorrhage. All presented with gastrointestinal bleeding, iron-deficiency anemia, and compatible antral biopsies. Using the large probe, vascular streaks were treated until the endoscopic appearance returned to normal (average four treatment sessions). No further bleeding was evident from the antral vascular ectasia over an average follow-up period of 20.9 months. Eight of 10 patients who had required transfusion prior to therapy no longer needed transfusion, but two received blood for other conditions. We conclude that antral vascular ectasia can be successfully treated with the HeatProbe Unit and this should be the initial modality of therapy for this condition.     

Detection of active bleeding from gastric antral vascular ectasia by capsule endoscopy

Gastric antral vascular ectasia(GAVE) has been recognized as one of the important causes of occult and obscure gastrointestinal bleeding.The diagnosis is typically made based on the characteristic endoscopic features,including longitudinal row of flat,reddish stripes radiating from the pylorus into the antrum that resemble the stripes on a watermelon.These appearances,however,can easily be misinterpreted as moderate to severe gastritis.Although it is believed that capsule endoscopy(CE) is not helpful for the study of the stomach with its large lumen,GAVE can be more likely to be detected at CE rather than conventional endoscopy.CE can be regarded as "physiologic" endoscopy,without the need for gastric inflation and subsequent compression of the vasculature.The blood flow of the ecstatic vessels may be diminished in an inflated stomach.Therefore,GAVE may be prominent in CE.We herein describe a case of active bleeding from GAVE detected by CE and would like to emphasize a possibility that CE can improve diagnostic yields for GAVE.     

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

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