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.

Ectasia vascular antral gastrica (GAVE) / Gastric antral vascular ectasia (GAVE)

La ectasia vascular antral gástrica (GAVE) ha sido reconocida como una de las causas importantes de hemorragia gastrointestinal oculta y oscura. El diagnóstico generalmente se realiza en función de los rasgos endoscópicos característicos, incluida la fila longitudinal de rayas planas y rojizas que irradian desde el píloro hacia el antro que se asemejan a las rayas de una sandía (Watermelon). Estas apariencias, pueden ser fácilmente malinterpretadas como una gastritis de moderada a severa. El diagnóstico del síndrome GAVE en pacientes con enfermedad renal o hepática suele ser problemático porque hay causas más frecuentes de hemorragia gastrointestinal en estas enfermedades como, por ejemplo, malformaciones vasculares, enfermedad ulcerosa péptica, várices esofágicas o gástricas y úlceras colónicas y rectales que eclipsan al síndrome GAVE. Creemos que el tratamiento quirúrgico es una modalidad cuando los diferentes métodos, no pudieron tratar de solucionar esta patología del GAVE. Probablemente en nuestro medio necesitamos más sospecha clínica de esta patología, como así mismo mayor experiencia en los tratamientos endoscópicos de tipo terapéuticos. Ante la falla de estos métodos, la cirugía , ya sea laparoscópica o convencional siguen teniendo lugar en la resolución de estos pacientes con patología poco común.

Gastric antral vascular ectasia (Gave) has been recognized as one of the important causes of hidden and dark gastrointestinal hemorrhage. The diagnosis is generally performed based on the characteristic endoscopic features, including the longitudinal row of flat and reddish stripes that radiate from the pylorus to the antrum that resemble the stripes of a watermelon (watermelon). These appearances can be easily misunderstood as moderate to severe gastritis. The diagnosis of the Gave syndrome in patients with renal or hepatic disease is usually problematic because there are more frequent causes of gastrointestinal bleeding in these diseases such as vascular malformations, peptic ulcerative disease, esophageal or gastric veins and colonic and rectal ulcers that eclipsan al Gave syndrome. We believe that surgical treatment is a modality when the different methods could not try to solve this pathology of the Gave. Probably in our environment we need more clinical suspicion of this pathology, as well as more experience in therapeutic endoscopic treatments. Given the failure of these methods, surgery, whether laparoscopic or conventional continue to take place in the resolution of these patients with unusual pathology.

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.

An Analysis of the Clinical, Laboratory, and Histological Features of Striped, Punctate, and Nodular Gastric Antral Vascular Ectasia.

BACKGROUND: Gastric antral vascular ectasia (GAVE) commonly presents as linear striped ("watermelon stomach") or punctate phenotypes, to which a newly discovered nodular form was recently added. AIMS: We performed a retrospective cohort study to detail and compare the clinical and histological characteristics of major GAVE phenotypes. METHODS: In 136 GAVE patients (tertiary care ambulatory and inpatient, median age 61.3 years, 73 men, and 63 women), clinical and laboratory results were recorded, with comorbidities, endoscopy indications, and complications of cirrhosis. In 74 patients, GAVE histopathology was cataloged by a pathologist masked to endoscopy results. RESULTS: Median age 61.3 years, 73 men, and 63 women. GAVE phenotypes were: linear striped-62 (46%), punctate-32 (24%), and nodular-41 (30%). Endoscopy was commonly performed for variceal screening in linear striped (45%) and nodular (34%) GAVE and for gastrointestinal bleeding in punctate (41%) and nodular (29%) GAVE, respectively. Of 89 cirrhotic patients, 37.5% each had linear striped or nodular GAVE, 24.7% had punctate forms (p = 0.03). Child-Turcotte-Pugh and Model for End-Stage Liver Disease scores were similar among phenotypes. Histologically, reactive epithelial hyperplasia and vascular ectasia were universal; smooth muscle proliferation was more common and consistent (78-86%) than microvascular thrombi (27-59%) and fibrohyalinosis (18-53%), which each varied with phenotype. CONCLUSIONS: Nodular GAVE is a gastric mucosal abnormality that is similar to the linear striped and punctate phenotypes, yet has distinct clinical and histological features. Increased awareness of nodular GAVE by endoscopists is needed to avoid its misdiagnosis as nonspecific antral nodules.

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.

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.

Imatinib-induced gastric antral vascular ectasia in three patients with chronic myeloid leukaemia.

Imatinib is generally well tolerated, but gastric antral vascular ectasia (GAVE) remains a rare but significant complication of imatinib therapy. Whilst this complication has been described in other disease settings, only one other case of GAVE has been reported in a chronic myeloid leukaemia (CML) patient receiving imatinib. Herein, we present three CML patients with GAVE complicating imatinib therapy. In all cases, GAVE resolved only with cessation of imatinib. This confirms a causal relationship between GAVE and imatinib. GAVE should be considered as a possible cause of anaemia and upper gastrointestinal bleeding in patients receiving imatinib therapy.

A rare case of watermelon stomach in woman with continuous ambulatory peritoneal dialysis and systemic lupus erythematosus.

We report a case of a 42-year-old woman with systemic lupus erythematosus and chronic kidney disease stage 5 undergoing continuous ambulatory peritoneal dialysis, presenting asthenia, dizziness, abdominal pain and small efforts dyspnea. After a complete physical and clinical examination, including laboratory tests, esophagogastroduodenal endoscopy and gastric lesions biopsy, she was diagnosed with gastric antral vascular ectasia. We are facing a rare case of antral vascular ectasia in a patient associating both chronic kidney disease and autoimmune disease.

Coronary artery calcification score is increased in patients with isolated coronary artery ectasia.

PURPOSE: Coronary artery calcification (CAC) is an indicator of coronary atherosclerosis and is associated with future adverse cardiac events. Isolated coronary artery ectasia (CAE) is defined as localized or diffuse dilation of the coronary arteries without coronary stenosis. The aim of this study was to assess the relationship between CAC and isolated CAE. METHODS: Thirty-four patients with isolated CAE and 50 controls subjects, with normal coronary arteries, were enrolled in the study. Baseline demographic features and atherosclerosis risk factors were similar in both groups. RESULTS: Patients with CAE had higher total CAC than control subjects (84±111 vs. 33.5±103.5; p<0.001). There was also a significant correlation between per-segment CAC and ectatic segment length (r=0.32; p=0.01) but no correlation with diameter (r=0.09; p=0.5). CONCLUSION: Patients with isolated CAE had higher CAC than control subjects, suggesting that atherosclerosis may be involved in the pathogenesis of isolated CAE. Patients with isolated CAE may have increased cardiovascular risk and should receive appropriate risk stratification and relevant medical treatment.

Gastric antral vascular ectasia: case report and review of the literature.

Gastric antral vascular ectasia is the source of up to 4% of nonvariceal upper gastrointestinal bleeding. It can present with occult bleeding requiring transfusions or with acute gastrointestinal bleeding. It is associated with significant morbidity and mortality and has been associated with such underlying chronic diseases as scleroderma, diabetes mellitus, and hypertension. Approximately 30% of cases are associated with cirrhosis. We report two cases of gastric antral vascular ectasia with two strikingly different endoscopic appearances. We further describe the clinical, endoscopic, histologic, and therapeutic aspects of this entity.

An unusual cause of upper GI bleeding: gastric antral vascular ectasia.

Gastric antral vascular ectasia (GAVE) is characterized by red patches or spots in either a diffuse or linear array in the antrum of the stomach. This syndrome is commonly referred to as watermelon stomach because of its typical endoscopic appearance. Patients with GAVE frequently have occult bleeding requiring continual transfusions. It is important to distinguish the differences while treating GAVE in cirrhotics and portal hypertensive gastropathy (PHG) since the treatment options are vastly different.

CD61, CD31, and CD34 improve diagnostic accuracy in gastric antral vascular ectasia and portal hypertensive gastropathy: An immunohistochemical and digital morphometric study.

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are unusual but important causes of gastrointestinal bleeding with characteristic endoscopic appearances and critically different therapies. However, overlapping features and poor endoscopic-histologic correlation make their distinction challenging. We sought to determine whether CD31, CD34 (vascular markers), and CD61 (platelet marker) could aid in their differentiation. Cases included 11 antral specimens with histologic diagnoses of GAVE, 11 histologically diagnosed as PHG, and biopsies of GAVE (15) or PHG (12) suspected on endoscopy but without histologic agreement. Controls consisted of endoscopically and histologically normal antrum. Image analysis of CD31 and CD34-stained sections was performed to determine mucosal microvessel density (MVD). CD61 revealed thrombi in 100% of histologically confirmed cases of GAVE and 60% of cases suspected of GAVE on endoscopy alone; control biopsies were negative. CD61 was also positive in 26% of cases originally signed out as PHG. Review of hematoxylin and eosin slides from these CD61-positive PHG cases showed other features allowing their correct reclassification as GAVE. MVD was significantly higher in GAVE than PHG. MVD in histologically confirmed PHG did not differ significantly from endoscopically suspected PHG. Review of hematoxylin and eosin slides from the latter showed active gastritis obscuring recognition of ectatic vessels. In conclusion, CD61 reliably differentiates GAVE from PHG. MVD analysis can also assist in their distinction. In PHG, the increased vascularity may be subtle in an inflammatory background; vascular markers may serve as adjunct markers for identifying the aberrant vessels.

Heterotopic mesenteric ossification after gastrectomy for watermelon stomach.

Heterotopic mesenteric ossification is a rare disorder. Only a few cases have been reported in the literature, associated with previous abdominal surgery or trauma. We report a case of heterotopic mesenteric ossification leading to abdominal sepsis, after abdominal operation for recurrent gastric bleeding, due to gastric antral vascular ectasia (GAVE), otherwise called "watermelon stomach", another rare disorder.