Comparisons Between Endoscopic Band Ligation, Radiofrequency Ablation and Endoscopic Thermal Therapy for Gastric Antral Vascular Ectasia: A Meta-Analysis.

BACKGROUND: Endoscopic band ligation (EBL) and radiofrequency ablation (RFA) have emerged as alternative therapies of gastric antral vascular ectasia (GAVE) in addition to endoscopic thermal therapy (ETT), but the optimum choice remains inconclusive. AIM: We conducted a meta-analysis in order to compare these three treatments for GAVE. METHODS: We searched the electronic databases of PubMed, Embase and Cochrane Central Register of Controlled Trials without any language restrictions and also performed a manual literature search of bibliographies located in both retrieved articles and published reviews for eligible publications prior to December 8, 2021. We included comparative trials which had evaluated the efficacy and safety of interventions in adults (aged ≥ 18 years) diagnosed with symptomatic GAVE and was confirmed according to clinical backgrounds and upper gastrointestinal endoscopy. We included reports that compared three interventions, ETT, EBL, and RFA. The study was comprised of adults diagnosed with GAVE and focused on overall mortality, bleeding cessation, endoscopic improvement, complications, hospitalization, hemoglobin improvement, number of sessions and transfusion requirements. RESULTS: Twelve studies were performed involving a total of 571 participants for analysis. When compared with ETT, EBL achieved better bleeding cessation (OR 4.48, 95% CI 1.36-14.77, p = 0.01), higher hemoglobin improvement (MD 0.57, 95% CI 0.31-0.83, p < 0.01) and lower number of sessions (MD - 1.44, 95% CI - 2.54 to - 0.34, p = 0.01). Additionally, EBL was superior to ETT in endoscopic improvement (OR 6.00, 95% CI 2.26-15.97, p < 0.01), hospitalization (MD - 1.32, 95% CI - 1.91 to - 0.74, p < 0.01) and transfusion requirement (MD - 2.66, 95% CI - 4.67 to - 0.65, p = 0.01) with statistical significance, with the exception of mortality (OR 0.58, 95% CI 0.19-1.77, p = 0.34) and complication rate (OR 5.33, 95% CI 0.58-48.84, p = 0.14). CONCLUSION: For GAVE, we suggest that EBL be initially recommended, and APC and RFA be used as alternative treatment choices based upon a very low quality of evidence.

Successful treatment of refractory Gastric Antral Vascular Ectasia (GAVE) in a cirrhotic patient with transcatheter arterial embolisation in a tertiary care facility in Pakistan: A case report.

Gastric antral vascular ectasia (GAVE) is a rare but important cause of upper gastrointestinal bleeding that may present with refractory anaemia or overt gastrointestinal bleeding requiring multiple admissions and resuscitation. Although endoscopic therapies are considered first line treatment for the management of refractory gastric antral vascular ectasia, angiographic embolisation of the culprit vessel(s) may emerge as an effective and safe treatment modality in the near future. Here, we present the case of a middle-aged gentleman with refractory gastric antral vascular ectasia, who was not responding to repeated sessions of Argon Plasma Coagulation (APC) and was successfully treated with trans-catheter arterial embolisation of gastro-duodenal artery.

Gastric antral vascular ectasia in a patient with lupus undergoing hemodialysis: a case report.

BACKGROUND: Gastric antral vascular ectasia (GAVE), associated with autoimmune diseases, such as systemic lupus erythematosus, and hepatic or renal disorders, is a rare cause of gastrointestinal bleeding. We report the case of a patient with lupus erythematosus undergoing hemodialysis with an uncorrectable anemia caused by GAVE. CASE PRESENTATION: A 76-year-old Korean woman with lupus undergoing hemodialysis frequently complained of symptoms or signs associated with anemia, such as dizziness, dyspnea, hypotension, melena, and hematemesis. Gastrointerstinal endoscopy revealed multiple erythematous and hyperemic mucosal lesions at the distal antrum without active bleeding, a finding compatible with GAVE. Although she frequently complained of symptoms or signs associated with anemia and had frequent gastrointestinal endoscopies with or without pre-emptive argon plasma coagulation, her clinical status is relatively stable, and she is undergoing maintenance hemodialysis without anticoagulants. CONCLUSION: This clinical case suggests that GAVE should be considered as a cause of the anemia resistant to erythropoiesis-stimulating agents and iron supplementation in patients with chronic kidney disease and lupus.

Mucosal miR-3677 is over-expressed in cirrhotic patients with gastric antral vascular ectasia (GAVE).

INTRODUCTION: Gastric antral vascular ectasia (GAVE) is a rare vasculopathy that associates several diseases, most commonly liver cirrhosis. It usually presents as an occult gastrointestinal bleeding leading to profound iron deficiency anemia. We hypothesized that GAVE is local mucosal pathology dependent on genetic mechanisms, and the purpose of the study was to characterize miRNAs expression in gastric tissue of patients with cirrhosis and GAVE. MATERIALS AND METHODS: Thirteen patients with GAVE and cirrhosis and 35 healthy subjects were recruited. Microarray analysis and comparative microRNA study was done by quantitative polymerase chain reaction (qPCR). The microarray scores were grouped with use of the hierarchical clusterization analysis and miRNA target prediction was done with TargetScan 6.2 algorithm and Gene Ontology analysis (DIANA-miRPath). RESULTS: Concentration of miR-3677 in GAVE-affected mucosa was higher by 72% in comparison with GAVE-free mucosa of patients with cirrhosis (33.7 vs. 35.6 PCR cycles; p < .001) and by 45% in comparison with normal mucosa (33.7 vs. 34.9 PCR cycles; p < .05). According to Gene Ontology analysis miR-3677 was related to angiopoietin-like protein 4 (ANGPTL4) gene. CONCLUSION: GAVE in liver cirrhosis is associated with increased expression of miR-3667 that may be linked with ANGPTL4 gene.

Gastric Antral Vascular Ectasia Pathogenesis and the Link to the Metabolic Syndrome.

PURPOSE OF REVIEW: Gastric antral vascular ectasia (GAVE) is a well-described source of chronic blood loss. We aim to review the previously hypothesized etiologies of GAVE and focus on recent proposed mechanisms, including metabolic syndrome. We will support these theories with newly discovered clinical associations and possible therapeutic implications. RECENT FINDINGS: Historically, GAVE has been associated with connective tissue disease and liver disease. Based on these associations and its histologic appearance, GAVE has presumed to be caused by mechanical- and hormonally mediated injury. Recent findings have been notable for a clinical association with aspects of the metabolic syndrome. Therefore, the pathogenic etiology may be akin to aspects of the metabolic syndrome via microvascular injury and neoangiogenesis. The potential etiologies of GAVE include hypergastrinemia, mechanical injury, and microvascular injury with neovascular proliferation particularly in the metabolic syndrome. Further research is needed to evaluate these proposed mechanisms and potential targets for treatment.

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. 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.

Helicobacter pylori, liver cirrhosis, and portal hypertension: an updated appraisal.

OBJECTIVE: Helicobacter pylori (H. pylori) is the most common cause of gastritis and peptic ulcer. However, H. pylori is even involved in extragastric diseases, and it has been hypothesized that H. pylori could be a risk factor for several hepatic diseases. For instance, a direct involvement of H. pylori in the development of portal hypertension (PH) in cirrhotic patients has been postulated. METHODS: We performed a literature search in major databases to elucidate the relationship between H. pylori, portal hypertension, and liver cirrhosis. RESULTS: The effect of H. pylori on PH may be multifactorial. Endothelial dysfunction, alterations in the vasodilating dynamics, and neoangiogenesis are the most appealing theories about this issue, but the proofs come mainly from experimental studies, therefore a solid pathophysiological basis is still to be demonstrated. Congestive gastropathy (CG) and gastric antral vascular ectasia (GAVE) are two common endoscopic entities responsible for acute/chronic upper gastrointestinal bleeding, and a link with H. pylori has been hypothesized: the gastric mucosa, exposed to H. pylori, could develop both inflammatory microcirculatory alterations and thrombi, resembling the histologic pattern of GAVE. CONCLUSIONS: Despite clues for an association between H. pylori and PH have been shown, these evidences are mostly experimental, therefore, in the absence of a direct proof on human beings, the role of H. pylori in the development of PH is uncertain. However, since this germ may be a cause of peptic ulcer, it should be found and eradicated in cirrhotic patients to reduce the risk of blood loss anemia.

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.

[Gastric vascular lesions in cirrhosis: gastropathy and antral vascular ectasia]. / Lesiones vasculares gástricas en la cirrosis: gastropatía y ectasia vascular antral.

Portal hypertensive gastropathy (GHP) is a complication of portal hypertension usually associated with liver cirrhosis. The pathogenesis is unclear but the presence of portal hypertension is an essential factor for its development. GHP may be asymptomatic or present as gastrointestinal bleeding or iron deficiency anemia. Endoscopic lesions vary from a mosaic pattern to diffuse red spots; the most common location is the fundus. Treatment is indicated when there is acute or chronic bleeding, as secondary prophylaxis. There is insufficient evidence to recommend primary prophylaxis in patients who have never bled. Drugs that decrease portal pressure, such as non-cardioselective beta-blockers, and/or endoscopic ablative treatments, such as argon-beam coagulation, may be used. The role of transarterial intrahepatic portosystemic shunt) or bypass surgery has been insufficiently analyzed. Antral vascular ectasia (EVA) is a rare entity in liver cirrhosis, whose pathophysiology is still unknown. Clinical presentation is similar to that of GHP and endoscopy usually shows red spots in the antrum. Biopsy is often required to differentiate EVA from GHP. There is no effective medical therapy, so endoscopic ablative therapy and, in severe cases, antrectomy are recommended.

Medical and endoscopic therapies for angiodysplasia and gastric antral vascular ectasia: a systematic review.

BACKGROUND & AIMS: Few studies have compared the efficacy and complications of endoscopic or medical therapies for bleeding angiodysplasias or gastric antral vascular ectasias (GAVE). We conducted a systematic review to evaluate therapies. METHODS: We performed a PubMed search for studies (written in English from January 1, 1980, through January 1, 2013) of medical or endoscopic treatment of bleeding angiodysplasias and GAVE. Measured outcomes included levels of hemoglobin, transfusion requirements, rebleeding rates, complications, treatment failures, and overall mortality. RESULTS: We analyzed data from 63 studies that met inclusion criteria; 50 evaluated endoscopic treatment (1790 patients), 13 evaluated medical treatment (392 patients), and 12 were comparative studies. In patients with angiodysplasias, the combination of estrogen and progesterone did not significantly reduce bleeding episodes, compared with placebo (0.7/y vs 0.9/y, respectively), and increased mortality, compared with conservative therapy (33% vs 21%). A higher percentage of patients receiving octreotide were free of rebleeding at 1 and 2 years vs placebo (77% vs 55% and 68% vs 36%, respectively; P = .03). Thalidomide reduced the number of bleeding episodes (-8.96/y), compared with iron therapy (-1.38/y, P < .01), but neither treatment reduced mortality. More patients with GAVE treated by endoscopic band ligation were free from rebleeding (92%) than those treated with argon plasma coagulation (32%, P = .01). CONCLUSIONS: In a systematic review, we found a low quality of evidence to support treatment of angiodysplasias with thalidomide or the combination of estrogen and progesterone and insufficient evidence to support treatment with octreotide. There is also insufficient evidence for endoscopic therapy of angiodysplasia or GAVE. Well-designed randomized controlled trials are needed to study the efficacy and complications of medical and endoscopic treatments for patients with angiodysplasias or GAVE.

Native Aortic Valve Endocarditis Secondary to Gastric Antral Vascular Ectasia Manipulation During Endoscopic Argon Plasma Coagulation.

Gastric antral vascular ectasia (GAVE) is an uncommon cause of upper gastrointestinal (GI) bleeds. Due to the high vascularity of the region, transient bacteremia due to manipulation of the GI tract can very rarely cause the translocation of bacteria. We present a rare case in which endoscopic manipulation to treat GAVE led to native valve infective endocarditis (IE). Our patient had a prior history of GAVE and presented with worsening dizziness and shortness of breath (SOB). After an esophagogastroduodenoscopy (EGD) and subsequent argon plasma coagulation (APC) for active preantral bleeding, the patient was noted to have repeated fevers, a new cardiac murmur, and positive blood cultures for Staphylococcus epidermidis, leading to a diagnosis of native infective endocarditis. With high clinical suspicion and early recognition of a new cardiac murmur, a transesophageal echocardiogram (TEE) was key in identifying vegetation. This case highlights the importance of combining history, a physical exam, and diagnostic lab tests and imaging to identify endocarditis. Management included two months of intravenous (IV) vancomycin and repeat TEE for close monitoring of vegetation improvement.

Recurrent Upper Gastrointestinal Bleeding due to Radiation-Induced Hemorrhagic Gastroduodenal Ectasia: A Review of Current Treatment Options for Radiation-Induced Gastric Injury.

Introduction: Acute upper gastrointestinal bleeding is one of the most common medical emergencies that present to the hospital, and delineating the underlying etiology is essential to provide adequate definitive treatment. The purpose of this case report was to review the diagnosis and treatment of a rare complication known as radiation-induced hemorrhagic gastritis (RIHG) that can occur in patients with prior radiation exposure. The motivation for this study arose from the identification of a case within our institution. Case Presentation: The study involved a review of the diagnosis and management of a patient who presented with anemia and recurrent episodes of gastrointestinal bleeding at our institution after undergoing treatment for metastatic biliary adenocarcinoma. With the advent of new therapies, we aimed to investigate the various techniques utilized to manage these patients and highlight the importance of maintaining a high index of suspicion for RIHG as a potential etiology of gastrointestinal bleeding in patients with a relevant medical history of radiation exposure. Despite the literature review, we found that there is a lack of guidelines in the approach to the management of these patients. Conclusion: This case report underscores the rarity of radiation-induced gastritis and the complications that may arise from its diagnosis, including recurrent GI bleeding. Further investigation into identifying definitive treatment and creating guidelines for its management is desperately needed.

Gastric Antral Vascular Ectasia: Resolution of Bleeding and Stabilization of Hematocrit Following Orthotopic Liver Transplantation.

Gastric Antral Vascular Ectasia (GAVE) is an uncommon cause of chronic gastrointestinal bleeding and iron deficiency anemia in the geriatric population. It is often associated with cirrhosis of the liver and is hypothesized to result from synthetic liver dysfunction. Treatment options include argon plasma coagulation, endoscopic band ligation, and radiofrequency ablation. An orthotopic liver transplant may be effective for patients with advanced liver disease. In this case report, we describe a 60-year-old woman with a history of cirrhosis secondary to nonalcohol-related steatohepatitis (NASH) and GAVE syndrome who presented with abdominal pain and melena. She had multiple prior episodes of gastrointestinal bleeding, leading to long-term transfusion dependency. An urgent esophagogastroduodenoscopy revealed the presence of GAVE with active bleeding. The patient was supported with blood transfusions and transferred to a transplant center, where she underwent orthotopic liver transplantation. Following the transplantation, her hemoglobin levels improved and remained stable. She was no longer noted to require any further blood transfusions during outpatient follow-up visits. This case report substantiates the role of synthetic liver dysfunction in the development of GAVE. Also, it suggests that patients with advanced cirrhosis and refractory GAVE may benefit from liver transplantation as a potential treatment option.

Radiofrequency ablation for refractory gastric antral vascular ectasia (with video).

BACKGROUND: Gastric antral vascular ectasia (GAVE) is a cause of upper GI bleeding and chronic anemia. Although upper endoscopy with argon plasma coagulation (APC) is an accepted therapy for GAVE, many patients continue to bleed and remain transfusion dependent after therapy. Radiofrequency ablation (RFA) may provide an alternative therapeutic option for GAVE. OBJECTIVE: To determine the efficacy and safety of RFA for patients with GAVE who remain transfusion dependent after APC treatment. DESIGN: Open-label prospective cohort study of patients with GAVE refractory to APC. SETTING: Academic tertiary referral center. PATIENTS: GAVE patients with previous failed APC therapy, chronic anemia, and transfusion dependence. INTERVENTIONS: Endoscopic RFA to the gastric antrum using the HALO(90) ULTRA ablation catheter until transfusion independence is achieved or a maximum of 4 sessions are performed. MAIN OUTCOME MEASUREMENTS: Transfusion requirements before and after RFA. Secondary outcomes are hemoglobin before and 6 months after RFA completion, number of RFA sessions, and complications. RESULTS: Twenty-one patients underwent at least 1 RFA session with ablation of GAVE lesions. At 6 months after completion of the course of RFA therapy, 18 of 21 patients (86%) were transfusion independent. Mean hemoglobin increased from 7.8 to 10.2 in responders (n = 18). Two adverse events occurred (minor acute bleeding and superficial ulceration); both resolved without intervention. LIMITATIONS: Single-center, single-operator, and nonrandomized design. CONCLUSIONS: RFA is safe and effective for treating patients with refractory GAVE after attempted APC.

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.

Band ligation of gastric antral vascular ectasia is a safe and effective endoscopic treatment.

BACKGROUND AND AIM: Gastric antral vascular ectasia (GAVE) or 'watermelon stomach' is a rare and often misdiagnosed cause of occult upper gastrointestinal bleeding. Treatment includes conservative measures such as transfusion and endoscopic therapy. A recent report suggests that endoscopic band ligation (EBL) offers an effective alternative treatment. The aim of the present study is to demonstrate our experiences with this novel technique, and to compare argon plasma coagulation (APC) with EBL in terms of safety and efficacy. METHODS: A retrospective analysis of all endoscopies with a diagnosis of GAVE was carried out between 2004 and 2010. Case records were examined for information pertaining to the number of procedures carried out, mean blood transfusions, mean hemoglobin, and complications. RESULTS: A total of 23 cases of GAVE were treated. The mean age was 73.9 (55-89) years. Female to male ratio was 17:6 and mean follow up was 26 months. Eight patients were treated with EBL with a mean number of treatments of 2.5 (1-5). This resulted in a statistically significant improvement in the endoscopic appearance and a trend towards fewer transfusions. Of the eight patients treated with EBL, six (75%) patients had previously failed APC treatment despite having a mean of 4.7 sessions. Band ligation was not associated with any short- or medium-term complications. The 15 patients who had APC alone had a mean of four (1-11) treatments. Only seven (46.7%) of these patients had any endoscopic improvement with a mean of four sessions. CONCLUSIONS: EBL represents a safe and effective treatment for GAVE.

A case of gastric antral vascular ectasia in which PuraStat, a novel self-assembling peptide hemostatic hydrogel, was effective.

Gastric antral vascular ectasia (GAVE) is a gastric hemorrhagic disease associated with chronic liver disease. Argon plasma coagulation is widely used to control gastrointestinal bleeding due to GAVE. Although argon plasma coagulation is a relatively safe endoscopic procedure, it is not suitable in some cases, such as in patients with pacemakers. We report a case of GAVE in which PuraStat, a novel self-assembling peptide hemostatic hydrogel, was effective. The patient was a 55-year-old man who had undergone Fontan surgery for tricuspid regurgitation more than 20 years prior. He developed hepatic cirrhosis as a complication following Fontan surgery. During upper gastrointestinal endoscopy to examine the cause of the progression of anemia and black stool, bleeding from GAVE was observed; PuraStat was applied to stop the bleeding. Postoperatively, the black stool disappeared, and his hemoglobin levels improved. Upper gastrointestinal endoscopy was performed 13 days after the surgery; the density of the capillaries in the antrum was significantly decreased, and a clear trend toward disappearance was observed. Therefore, the application of PuraStat may be useful in the treatment of GAVE.

A Case of Refractory Gastric Antral Vascular Ectasia Treated Successfully With Distal Gastrectomy and Billroth II Reconstruction.

Gastric antral vascular ectasia is a rare cause of upper gastrointestinal bleeding and an important cause of transfusion dependence. Although surgery should be considered when patients with gastric antral vascular ectasia become transfusion-dependent even after endoscopic treatment, surgery for such patients with cirrhosis on dialysis has not been reported. Our patient, a 62-year-old man with a history of cirrhosis and chronic kidney failure, experienced recurrent bloody stool. Upper endoscopic findings indicated a diagnosis of gastric antral vascular ectasia; therefore, we initiated therapy with argon plasma coagulation. Anemia developed, and despite a second argon plasma coagulation treatment, it remained difficult to control. During the six weeks of hospitalization, the patient received more than 40 units of red blood cells. The gastroenterologist determined that further treatment with argon plasma coagulation would increase the risk of gastric perforation; therefore, we performed distal gastrectomy with Billroth II reconstruction. The patient was discharged from the hospital 15 days after surgery and had no signs of anemia for more than one year after discharge. The case of our patient shows that although endoscopic therapy is the usual treatment for gastric antral vascular ectasia, surgery should be considered when anemia is difficult to control.