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.     

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 mucosal resection for recurrent gastric antral vascular ectasia

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.     

Endoscopic biopsy is diagnostic in gastric antral vascular ectasia

Gastric antral vascular ectasia was endoscopically diagnosed in seven patients. Pathologic characteristics of this entity were defined retrospectively, by studying endoscopic pinch biopsy slides from these seven patients and antrectomy specimens from five patients. A scoring system was developed, and the seven patients were compared prospectively with various control groups. Abnormalities of mucosal vessels (fibrin thrombi and/or ectasia) consistently distinguished patients from control antrectomies, normal biopsies, acute gastritis biopsies and atrophic gastritis biopsies (P=0.02, all comparisons). Spindle cell proliferation into mucosa also was characteristic of gastric antral vascular ectasia, distinguishing this disease from normals, acute gastritis, and atrophic gastritis (P0.039, each comparison). The presence of abnormal mucosal vessels (fibrin thrombi and/or ectasia) and spindle cell proliferation was similar in patient antrectomies compared to patient endoscopic biopsies. Therefore, we conclude that endoscopic biopsies can reliably diagnose gastric antral vascular ectasia, a vascular disorder characterized by abnormal mucosal vessels and spindle cell proliferation.     

Massive gastric antral vascular ectasia successfully treated by endoscopic band ligation as the initial therapy

Gastric antral vascular ectasia(GAVE) accounted for 4% of non-variceal gastrointestinal hemorrhage.Even though unclear pathogenesis,GAVE often associated with chronic renal failure,autoimmune diseases and cirrhosis.Asymptomatic lesions were reasonably not to treated.The treatment options for GAVE are nonendoscopic and endoscopic treatments.For the pharmacological treatment,some success were reported for the use of octreotide,thalidomide and tranexamic acid.While the endoscopic treatment is the mainstay for treatment of symptomatic lesions.The endoscopic ablative therapies such as argon plasma coagulation was reported with good clinical outcomes.However,these treatment options had some limitation due to the need of special equipment and multiple sessions needed to control the bleeding.We reported another treatment option using the routine-achievable instrument such as endoscopic band ligation as an initial treatment which also provided a good treatment outcome and less sessions.     

Endoscopic laser treatment of diffuse gastric antral vascular ectasia.

Eight patients (six women and two men) were found to have iron deficiency anaemia due to diffuse gastric antral vascular ectasia. The mean age of the patients was 74.6 years (range 57-83). All required repeated blood transfusions (mean 18 units/year) before treatment. Five patients were classified as having the ''watermelon stomach'' (group A) and three the ''honeycomb stomach'' (group B), according to criteria described in previous reports. All were treated using neodymium:YAG laser photocoagulation. Significant endoscopic improvement and reduction in blood requirements were noticed in group A in which only one patient required a transfusion after treatment. Results in group B were disappointing. One patient was operated on and the other two still require blood transfusions. Laser treatment was safe in both groups and no major complications were encountered.     

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.     

Successful treatment of refractory gastric antral vascular ectasia using transcatheter arterial embolization

In January 2008, a 67-year-old woman was admitted to our hospital because of hepatitis C virus-related cirrhosis and hepatocellular carcinoma (HCC). In February 2010, she had tarry stools and anemia resulting from gastric antral vascular ectasia (GAVE). Argon plasma coagulation (APC) treatment for GAVE was performed at that time. She revisited our hospital in July 2010 because of tarry stools and anemia caused by GAVE recurrence, which required 5 APC sessions and blood transfusion to control the bleeding. In October 2010, she arrived at our hospital by ambulance because of hemorrhagic shock resulting from GAVE recurrence. Despite performing 5 APC sessions and multiple blood transfusions, the tarry stools and anemia persisted during the hospitalization period. In December 2010 and January 2011, second-stage selective transcatheter arterial embolization (TAE) of the right gastric and right gastroepiploic arteries using microcoils was performed for the treatment of the refractory GAVE. Upper gastrointestinal endoscopy performed after TAE revealed the disappearance of mucosal diffuse spotty redness. In addition, no complications such as gastric ulcer and necrosis were observed. Selective TAE, effectively resolved the GAVE and anemia, and no recurrence has been observed during the last 24 months. Therefore, TAE may be a safe and radical treatment for refractory 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.     

Antral motility in patients with cirrhosis with or without gastric antral vascular ectasia.

Gastric motility has not been extensively studied in patients with cirrhosis and gastric antral vascular ectasia (GAVE) may be associated with antropyloric dysfunction. This study therefore looked at antral motility using ultrasound in patients with alcoholic cirrhosis with or without GAVE. Twenty six patients were included: 10 patients with cirrhosis without GAVE, eight patients with cirrhosis and GAVE, and eight controls without liver disease. Measurement of antral area and antral contractions (amplitude and frequency) was performed for three hours after ingestion of a standardised solid-liquid meal. Antral area half time (mean (SD)) was not significantly increased in patients with cirrhosis without GAVE (84 (42) min), but increased by 120% (123 (43) min; p < 0.01) in patients with GAVE compared with controls (56 (26) min). GAVE patients exhibited the same frequency and amplitude of antral contractions at each time point as controls and had the same tendency to increase these values over time although this was attenuated in the late postprandial phase. In contrast, cirrhotic patients without GAVE exhibited a significantly higher frequency and amplitude of antral contractions during the initial postprandial phase but showed no change in either frequency or amplitude over time. In conclusion, in cirrhosis there is an abnormal antral motor response to a meal, which has a different pattern over time in patients with or without GAVE.     

Endoscopic band ligation for postpolypectomy gastric bleeding

We report a case of a patient in whom endoscopic band ligation was achieved for postpolypectomy gastric bleeding. A 76‐year‐old man visited our hospital because of anemia. Endoscopy revealed a gastric polyp, approximately 12 mm in diameter, on the lesser curvature in the distal gastric body. The polyp was considered to be the source of chronic anemia and was therefore removed by using standard careful snare‐cautery polypectomy technique. Four days later, follow‐up endoscopy was performed to evaluate the postpolypectomy site, and an active bleeding postpolypectomy ulcer was identified. Initial attempts to achieve hemostasis with ethanol injection were unsuccessful. Immediate hemostasis was obtained with a subsequent endoscopic band ligation device. There has been no recurrent bleeding. Endoscopic band ligation might be a good treatment modality for the treatment of a postpolypectomy gastric bleeding lesion.     

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.     

Intravenous cyclophosphamide as a therapeutic option for severe refractory gastric antral vascular ectasia in systemic sclerosis

Gastric antral vascular ectasia (GAVE) is a rare but important cause of upper gastrointestinal bleeding. It is commonly associated with autoimmune conditions such as systemic sclerosis, and standard treatment involves both supportive measures, as well as endoscopic interventional therapies. While the current therapies are effective for most patients, a few patients develop severe and refractory bleeding. Herein we report two cases of refractory GAVE in patients with diffuse scleroderma, which improved significantly after the administration of intravenous cyclophosphamide. One of these cases is, to our knowledge, the first reported case of cyclophosphamide being used specifically for the treatment of refractory GAVE.