Role of Endoscopy in the Diagnosis, Grading, and Treatment of Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia.

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are 2 distinct gastric vascular abnormalities that may present with acute or chronic blood loss. PHG requires the presence of portal hypertension and is typically associated with chronic liver disease, whereas there is controversy about the association of GAVE with chronic liver disease and/or portal hypertension. Distinguishing between GAVE and PHG is crucial because their treatment strategies differ. This review highlights characteristic endoscopic appearances and the clinical features of PHG and GAVE, which, in turn, aid in their appropriate management.

Resolution of gastric antral vascular ectasia following cessation of imatinib.

A female patient in her 80s presented with chronic iron-deficiency anaemia secondary to gastric antral vascular ectasia (GAVE), despite repeated endoscopic treatment. Her medical history was notable for chronic myeloid leukaemia, for which she took imatinib. Due to a possible association between imatinib and GAVE described in a small number of case reports, cessation of imatinib was trialled. This led to a significant improvement in the patient's anaemia and resolution of GAVE on repeat endoscopy. GAVE is an uncommon cause of gastrointestinal bleeding, the aetiology of which is uncertain. This report describes an approach to the differential diagnosis of chronic iron-deficiency anaemia and an overview of GAVE syndrome. It illustrates the benefit of broadening the differential when the diagnosis is uncertain and the utility of case reports in informing the differential diagnosis.

In Search of Nodular Gastric Antral Vascular Ectasia: A Distinct Entity or Simply Hyperplastic Polyps Arising in Gastric Antral Vascular Ectasia?

CONTEXT.­: Nodular gastric antral vascular ectasia (GAVE) is a reported phenotype of GAVE that has histologic features overlapping with gastric hyperplastic polyps (GHPs), with additional features often seen in flat mucosa of GAVE. OBJECTIVE.­: To determine if nodular GAVE and GHPs are distinct lesions by evaluating the prevalence of features reported in nodular GAVE in GHPs with or without associated GAVE. DESIGN.­: A review of all lesions diagnosed as GHPs between 2014 and 2017 was performed. Slides were analyzed for a number of features including established histologic features of GAVE without knowledge of clinical or endoscopic features. RESULTS.­: A total of 90 polyps were analyzed including 18 from patients with GAVE (20%). GAVE polyps were larger than non-GAVE polyps (average size, 1.3 cm versus 0.68 cm; P < .001), with more common extensive ulceration and associated granulation tissue (61.11% [n = 11] versus 4.17% [n = 3]; P = .004), fibrin thrombi (50% [n = 9] versus 15% [n = 11]; P = .003), moderate to marked vascular ectasia (83% [n = 15] versus 35% [n = 11]; P = .001), and fibrohyalinosis (72% [n = 13] versus 28% [n = 20]; P = .001). All polyps showed foveolar hyperplasia and smooth muscle proliferation. There were no features that were exclusively found in GAVE or non-GAVE cases. CONCLUSIONS.­: Nodular GAVE appears to represent GHPs arising in a background of GAVE, with superimposed features found in flat mucosa of GAVE stomachs. The presence of fibrin thrombi, marked vascular ectasia, fibrohyalinosis, and/or ulceration in a GHP is suggestive but not diagnostic of GAVE, and the absence of these features does not rule out GAVE.

Severe Anemia Caused by Gastric Antral Vascular Ectasia and Autoimmune Gastritis.

An 80-year-old man presented to our hospital with general fatigue on exertion that had gradually worsened over 6 months. His blood test revealed severe anemia, and gastroscopy revealed findings consistent with gastric antral vascular ectasia (GAVE) and autoimmune gastritis. We diagnosed the patient with severe anemia caused by GAVE and autoimmune gastritis. The present case suggested that GAVE is triggered by autoimmune gastritis, and the mechanism is likely related to hypergastrinemia. The reporting of this rare case may help elucidate the cause of GAVE, which is currently unknown.

Magnifying endoscopy with narrow-band image for diagnosing diffuse type of gastric antral vascular ectasia in cirrhotic patients.

OBJECTIVE: Gastric antral vascular ectasia (GAVE) and portal hypertensive gastropathy (PHG) can cause gastrointestinal bleeding in cirrhotic patients. Distinguishing diffuse-type GAVE and severe PHG is important but difficult by conventional endoscopy and endoscopic biopsy. The aim of this study is to evaluate the value of magnifying endoscopy with narrow-band image for diagnosing diffuse-type GAVE in cirrhotic patients. METHODS: From January 2010 to December 2013, cirrhotic patients with diffuse red spots of stomach in suspicion of diffuse-type GAVE on conventional endoscopy in a tertiary medical center were included. The detection of diffuse red spots on magnifying endoscopy with narrow-band image (NBI) was classified into ring-pattern which suggested GAVE and mosaic-pattern which suggested non-GAVE. The golden diagnosis of GAVE was based on histological criteria of GAVE score ≥3 by any one of two endoscopic sessions. RESULTS: Total 27 cirrhotic patients were included. Twenty-two patients reached the diagnosis of GAVE and five patients were diagnosed of non-GAVE by histology. The diagnostic rate of conventional endoscopy was 81.5% (22/27). The positive rate of initial endoscopic biopsy was 77.2%. On magnifying endoscopy with NBI, the sensitivity, specificity, positive, negative predicted rate and accuracy of ring-pattern for the diagnosis of GAVE were 100, 90, 96.4, 100 and 97.3%. Kappa coefficient of inter-observer agreement for differentiating the ring and mosaic-pattern was 0.92. CONCLUSIONS: The efficacy and accuracy of magnifying endoscopy with NBI for diagnosing diffuse-type GAVE in cirrhotic patients have been demonstrated. It can avoid repeated endoscopy to confirm diagnosis and obviate the invasive biopsy in cirrhotic patients.

Gastric antral vascular ectasia in children, rare presentation.

A 14-year-old boy, a known case of perinatal hypoxic cerebral palsy, presented to paediatric emergency with acute melaena and blood staining around feeding gastrostomy site. Physical examination revealed pallor, but no signs of distress with an unremarkable abdominal examination. Routine blood tests revealed normochromic. Abdominal ultrasound scan and Meckel's scan were unremarkable. The patient underwent examination under anaesthesia of the perianal area and joint upper and lower gastrointestinal endoscopy. Streak-like gastritis with no signs of active bleeding lesions were noted and patchy areas of colitis involving the descending and sigmoid colon and the rectum. All clinical findings and evidence-based diagnosis matched gastric antral vascular ectasia. He was successfully managed conservatively with elemental hydrolysed feeding formula.

[A case of gastric antral vascular ectasia improved by splenorenal shunt embolization].

An 80-year-old man with chronic renal failure and a splenorenal shunt was admitted because of progressive anemia. Gastrointestinal endoscopy revealed bleeding from a gastric antral vascular ectasia (GAVE). Despite treatment with argon plasma coagulation and blood transfusions on multiple occasions, anemia caused by GAVE bleeding recurred frequently. The GAVE improved after splenorenal shunt embolization, and the patient did not require further blood transfusions for anemia. In this case, we inferred that some humoral factor (e.g., gastrin) in the portal blood caused the GAVE.

Radiofrequency ablation for patients with refractory symptomatic anaemia secondary to gastric antral vascular ectasia.

Background: Gastric antral vascular ectasia (GAVE) is a rare cause of gastrointestinal bleeding, often causing iron deficiency anaemia. Previous studies have looked at the management of this with argon plasma coagulation, laser therapy and endoscopic band ligation. Methods: This was a single-centre prospective study to evaluate the efficacy and safety of radiofrequency ablation (RFA) in patients with GAVE with persistent anaemia refractory to at least one session of first-line endoscopic therapy. Patients were treated with a through-the-scope (TTS) radiofrequency catheter at two endoscopic sessions six weeks apart. The primary outcome was change in haemoglobin at six months posttreatment. The secondary outcomes were reduction in blood or iron requirements, endoscopic surface area regression and complications. Results: Twenty patients were treated. The mean change in haemoglobin at six months was +12.6 g/l (95% confidence interval 11.7-24.3 g/l), paired t test p < 0.001. At six months, three of 14 individuals who had required blood transfusions had ongoing blood transfusions and five of 17 who had required iron had ongoing iron needs. Surface area regression was scored as 74% ± 25% but no correlation was seen between this and other outcomes. Three of 20 patients experienced pain which was managed with oral analgesia. Of the 14 patients who had reached 12-month follow-up, three required retreatment (21%). Discussion: This small study suggests that RFA is a safe and effective treatment for GAVE. Our study uses the TTS catheter compared to other studies, and demonstrates prolonged improvement in haemoglobin and reduction in blood and iron requirements with a novel assessment of surface area regression.

Elevated Gastric Antrum Erosions in Portal Hypertension Patients: Peptic Disease or Mucosal Congestion?

BACKGROUND/AIMS: Portal hypertension (PH) is a syndrome characterized by chronic increase in the pressure gradient between the portal vein and inferior vena cava. Previous studies have suggested an increased frequency of antral elevated erosive gastritis in patients with PH, as well as an etiologic association; however, there has not been any histological evidence of this hypothesis to date. Our aim was to evaluate the histological features found in elevated antral erosions in patients with portal hypertension. METHODS: Sixty-nine patients were included; 28 with and 41 without PH. All patients underwent endoscopy, and areas with elevated antral erosion were biopsied. RESULTS: In the PH group, 24 patients had inflammatory infiltration with or without edema and vascular congestion, and 4 patients had no inflammation. In the group without PH, all patients showed inflammatory infiltration of variable intensity. There was no statistical significance between the two groups in the presence of Helicobacter pylori. There as a histological similarity between the two groups, if PH patients without inflammation were excluded; however, more edema and vascular congestion were observed in the PH group (p=0.002). CONCLUSIONS: The findings show that elevated antral erosions in patients with PH have more evident edema and vascular congestion in addition to lymphocytic infiltration.

Orthotopic liver transplantation changes the course of gastric antral vascular ectasia: a case series from a transplant center.

BACKGROUND AND AIM: Gastric antral vascular ectasia (GAVE) is an important cause of upper gastrointestinal bleeding and anemia in patients with cirrhosis. The aim of our study was to evaluate the effect of orthotopic liver transplantation (OLT) on GAVE and associated anemia. PATIENTS AND METHODS: We performed a chart review and identified all cirrhotic patients with GAVE who underwent OLT at the University Of Alabama at Birmingham between 2005 and 2013. Population's demographics, etiology of cirrhosis, comorbidities, presentation and treatment modalities of GAVE, endoscopic and histopathologic reports, hemoglobin values before and after transplant, and immunosuppressive regimens were collected. RESULTS: Twelve patients were identified, mean age 52.4±4.4 years; seven were men (58.3%); 11 (91.7%) were White; and 6 of 12 patients had biopsy-proven GAVE. The most common etiology of cirrhosis in the cohort was chronic hepatitis C and obesity was the most common chronic condition in 50 and 83.3%, respectively. Anemia resolution was observed in 9/12 (75%) patients who underwent OLT with an increase in hemoglobin from 8.1±2.4 (5.7-13.1) before transplant to 12.0±1.4 (10-15) after transplant (P<0.0001). Esophagogastroduodenoscopy after transplant was performed in all 12 (100%) patients. The mean time between transplant and post-OLT esophagogastroduodenoscopy was 13.8±18.28 (2-57) months; complete resolution of GAVE was observed in 10 (83.3%) patients, with resolving GAVE in one (8.3%) patient. CONCLUSION: GAVE is an important cause of anemia and upper gastrointestinal bleeding in patients with liver cirrhosis. Our findings show that liver transplantation can resolve GAVE and related anemia.

Gastric antral vascular ectasia in systemic sclerosis: Where do we stand?

Gastric antral vascular ectasia (GAVE) continues to be a challenge in both diagnosis and treatment. GAVE has a diverse group of associations and presumed causes, including cirrhosis, chronic renal failure and autoimmune connective tissue diseases. However, in most occasions, the management plan of GAVE itself is the same whatever the underlying disease by using Argon plasma coagulation (APC). Herein, we will discuss three cases of systemic sclerosis-associated GAVE presenting with either acute or chronic gastrointestinal bleeding showing variable responses to APC. Anemia and telangiectasia may be the first striking presentation of systemic sclerosis (SSc). Renal artery stenosis, aortic stenosis, widespread cutaneous and mucosal telangiectasia and hypertension seem to be associated with poor prognosis and should prompt rapid intervention and careful follow-up. Moreover, the hunt for molecular underpinnings of the broad array of vascular lesions in SSc has to include von Willebrand factor and endoglin. Eventually, we will review the recent alternatives that can be effective in SSc-GAVE, such as band ligation, hematopoietic stem cells transplantation and immunotherapy.

The Efficacy of Virtual Chromoendoscopy in the Diagnosis of Portal Hypertensive Gastropathy.

BACKGROUND: Diagnosis of portal hypertensive gastropathy (PHG) is based on endoscopic criteria. I-scan technology, a new technique of virtual chromoendoscopy, increases the diagnostic accuracy for lesions in the gastrointestinal tract. AIM: To establish the role of i-scan endoscopy in the diagnosis of PHG. METHOD: In this prospective study, endoscopic examination was conducted first by using white light and after that i-scan 1 and i-scan 2 technology in a group of 50 consecutive cirrhotic patients. The endoscopic diagnostic criteria for PHG followed the Baveno criteria. The interobserver agreement between white light endoscopy and i-scan endoscopy was determined using Cohen's kappa statistics. RESULTS: Forty-five of the 50 patients met the diagnostic criteria for PHG when examined by i-scan endoscopy and 39 patients were diagnosed with PHG by white light endoscopy. The strength of agreement between the two methods for the diagnosis of PHG was moderate (k=0.565; 95%CI 0.271-0.859; p<0.001). I-scan 1 classified the mosaic pattern better than classic endoscopy; i-scan 2 described better the red spots. CONCLUSION: I-scan examination increased the diagnostic sensitivity of PHG. The diagnostic criteria (mosaic pattern and red spots) were easier to observe endoscopically using i-scan than in white light.

Systemic mastocytosis: A rare cause of non-cirrhotic portal hypertension.

Mastocytosis is a clonal neoplastic disorder of the mast cells (MC) that can be limited to the skin (cutaneous mastocytosis) or involve one or more extracutaneous organs (systemic mastocytosis). The clinical manifestations of mastocytosis are heterogeneous ranging from indolent disease with a long-term survival to a highly aggressive neoplasm with survival of about 6 mo. Although liver involvement in aggressive systemic mastocytosis (ASM) is relatively common, the development of portal hypertension with or without cirrhosis is rare. We report a case of ASM without skin involvement in a 72-year-old caucasian male who presented with non-cirrhotic portal hypertension based on clinical, analytical, imagiological and endoscopic findings. Given the hematological picture, the correct diagnosis was established based on ancillary tests for MC using bone marrow aspirates and biopsy. Extensive involvement of the liver and gastrointestinal tract was histologically documented. The disease progressed rapidly and severe pancytopenia and recurrent upper gastrointestinal bleeding became the dominant problem. This case illustrates the challenge in establishing a diagnosis of ASM especially when the clinical picture is atypical and without skin involvement. Gastroenterologists should consider infiltrative disease, particularly systemic mastocytosis, as a differential diagnosis in a clinical case of portal hypertension of unknown etiology.

[VENOUS ECTASIA OF GASTRIC ANTRUM].

Gastric antral vascular ectasia (GAVE) is an uncommon but often severe cause of upper gastrointestinal bleeding. GAVE may be asymptomatic or accompanied by clinical anemia or overt gastrointestinal bleeding. The diagnosis is mainly based on pathognomonic endoscopic pattern, defined as «watermelon stomach¼, located in antrum. Autoimmune disorders aye co-existing in about 60% of patients with GAVE, chirrosis in about 30%, and cardiac or renal failure in 10%.The "golden standarden" treatment of GAVE is endoscopic argon plasma coagulation (APC). There is poor information about diagnostics and treatment of GAVE in the domestic literature. The analysis of the presented materials shows that correct diagnostics takes much time and the choice of the optimum optimal treatment strategy encounters difficulty. Our experience with diagnostics and therapy of GAVE is based on the treatment of 4 patients. The diagnosis of GAVE was established within the period from 5 months to 1.5 years after onset of the disease. In two cases, GAVE was asymptomatic. Two patients with severe anemia completed endoscopic treatment; in one case, APC was supplemented by laser coagulation and bipolar coagulation. The implementation of laser coagulation caused some technical difficulties. Treatment of both patients was successful. Endoscopy pivotal for diagnosis of GAVE is the main method of its treatment. Due to the large number of diagnostic errors and the importance of correct diagnosis of GAVE, it is necessary to pay attention to this issue in training programs for endoscopists.

Portal hypertensive gastropathy and gastric antral vascular ectasia.

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are gastric mucosal lesions that mostly present as chronic anemia and rarely cause the acute gastrointestinal hemorrhage. Despite similar clinical manifestations, their pathophysiology and management are entirely different. PHG is seen exclusively in patients with portal hypertension, but GAVE can also be observed in patients with other conditions. Their diagnosis is endoscopic, and although generally each of them has a characteristic endoscopic appearance and distribution, there are cases in which the differential is difficult and must rely on histology. This review focuses on the management of both entities. The mainstay of management of PHG is based on portal-hypotensive pharmacological treatment while GAVE benefits from hormonal therapy, endoscopic Nd:YAG laser, and argon plasma coagulation. More invasive options should be reserved for refractory cases.

Refractory gastric antral vascular ectasia: a new endoscopic approach.

Gastric antral vascular ectasia (GAVE) is an uncommon disorder observed in patients with liver cirrhosis, causing upper gastro-intestinal haemorrhage. GAVE is diagnosed through esophagogastroduodenoscopy and is characterized by the presence of visible columns of red tortuous enlarged vessels along the longitudinal folds of the antrum (i.e., so-called watermelon stomach). Pharmacological, endoscopic and surgical approaches have been proposed for the treatment of GAVE. Endoscopy represents the gold standard for GAVE treatment. The most widely used endoscopic approach is represented by Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser. Argon plasma coagulation (APC) has been proven to be more efficient in terms of costs and complication rates than and equally effective as Nd:YAG. Other endoscopic procedures proposed for this treatment are banding ligature (EBL) and sclerotherapy with Polidocanol. Refractory GAVE represents a therapeutic challenge because it may cause persistent anemia, often leading to repeated blood transfusions due to the inefficacy of pharmacological and endoscopic therapeutic approaches. Endoscopic band ligation (EBL) has been shown to be superior to APC in the treatment of refractory GAVE. Surgical antrectomy by Billroth I anastomosis can be considered in selected cases. In this study, we report a successful endoscopic treatment of refractory GAVE by using a combination of submucosal injection of 1% Polidocanol at the four antral quadrants and subsequent application of APC on the visible antral lesions in two patients.