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.

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.

Alternativas terapéuticas para el manejo de la ectasia vascular gástrica antral (GAVE) / Alternatives for the treatment of gastric antral vascular ectasia (GAVE)

Gastric antral vascular ectasia is an unusual cause of upper gastrointestinal bleeding. The most frequent clinical presentation is iron deficiency anemia in a female patient older than 60 years. A third of patients have liver cirrhosis or a connective tissue disease, especially those related to Raynaud’s syndrome and scleroderma. The severity of this condition is variable, in some cases iron supplements are enough, while in other transfusion requirements are permanent. Currently the therapies most frequently reported in literature are argon plasma coagulation, radiofrequency ablation and endoscopic band ligation of antral mucosa. This article aims to review the available evidence for the management of this condition.

La ectasia vascular gástrica antral es una causa infrecuente de hemorragia digestiva alta cuya forma de presentación más habitual es la anemia ferropriva en una mujer mayor de 60 años. Un tercio de los pacientes tiene antecedente de cirrosis hepática o enfermedades del tejido conectivo relacionadas al síndrome de Raynaud o esclerodermia. El compromiso es de intensidad variable, sin embargo, en casos graves los pacientes pueden requerir transfusiones en forma permanente. En la actualidad las terapias más frecuentemente reportadas en la literatura son la termocoagulación con argón plasma, la ablación con radiofrecuencia y la ligadura de mucosa antral con bandas elásticas. El objetivo principal de este artículo es revisar la evidencia disponible para el manejo de esta condición.

Efficacy of neodymium:YAG laser therapy for gastric antral vascular ectasia (GAVE) following hematopoietic cell transplant.

We determined the incidence of severe bleeding from gastric antral vascular ectasia (GAVE) after myeloablative hematopoietic cell transplant and the outcomes after treatment with endoscopic neodymium:YAG laser photocoagulation. From 1992 to 2005, the incidence of severe bleeding from GAVE was 6/4491 (0.13%). All patients had received oral busulfan and four had sinusoidal obstruction syndrome. Gastrointestinal bleeding began a median of 53 days after transplant (range 15-2952). After GAVE was diagnosed by endoscopic and histologic findings, a median of three (range 2-7) sessions of laser therapy were required to control the bleeding with a median of 2737 J (range 1117-6160 J) per session. A median of 16 units (range 4-44) had been transfused prior to laser therapy and a median of four additional units (range 0-113) were transfused until bleeding was controlled. All patients were followed for at least 70 days after the last laser therapy session, with no further episodes of bleeding. Complications were mild and included abdominal pain and asymptomatic ulceration; however, one patient required gastrectomy due to gastric necrosis following transarterial embolizations. In summary, severe bleeding from GAVE is rare following hematopoietic cell transplant. Treatment with endoscopic therapy using the Nd:YAG laser is safe and effective.

[Gastric antral vascular ectasia:clinical presentation and therapeutic management]. / Ectasia vascular antral gástrica: presentación clínica y manejo terapéutico.

The gastric antral vascular ectasia (GAVE) or watermelon stomach is an increasingly recognized cause of persistent upper gastrointestinal bleeding, which has typical endoscopic and histological findings. This disease is most frequent in elderly women, and several associated conditions have been well established. Some patients with severe portal hypertensive gastropathy may have a GAVE like appearence. Nevertheless, a correct diagnosis is relevant in order to choose an appropiate treatment. The objective of the current study is to analyze the clinical features and treatment of a group of patients with GAVE evaluated at our Institution. A review of the current literature was also performed. Six women and three men with GAVE were admitted at the Buenos Aires British Hospital between November 1998 and January 2004. Endoscopic biopsy was performed in eight patients and was consistent with GAVE in all cases. Four patients with chronic anaemia as unique manifestation were successfully treated with iron supplements. Endoscopic treatment was performed in 4 patients, 3 of them were treated with bipolar electrocautery and 1 with argon plasma coagulation. An antrectomy was carried out in the ninth patient. The resolution of the bleeding was observed in all cases with the different therapeutics options used.

Ectasia vascular antral gástrica: presentación clínica y manejo terapéutico / Gastric antral vascular ectasia: clinical presentation and therapeutic

La ectasia vascular antral gástrica (GAVE) o watermelon stomach es un causa de hemorragia digestiva alta cuyo reconocimiento se ha incrementado, la cual posee características endoscópicas e histológicas típicas. La enfermedad es más frecuente en mujeres ancianas y varias entidades asociadas han sido bien establecidas. Si bien algunos pacientes con gastropatía asociada a la hipertensión portal pueden presentar un aspecto similar a la GAVE, la distinción resulta de interés a los fines de elegir una terapéutica apropiada. El objetivo de este estudio es analizar las características clínicas y el tratamiento de un grupo de pacientes con GAVE evaluados en nuestra institución. Asimismo, se realizóuna revisión de la bibliografía actual. Seis mujeres tres hombres con GAVE fueron admitidos en el Hospital Británico de Buenos Aires entre noviembre de 1998 y enero de 2004. Se realizó biopsia endoscópica en ocho pacientes, siendo consistente con GAVE en todos los casos. Cuatro pacientes con anemia crónica como única manifestación fueron exitosamente tratados con suplementos de hierro. Se realizó tratamiento endoscópico en cuatro pacientes, tres de ellos con electrocauterio bipolar y uno con coagulación con argón plasma. El paciente restante fue sometido a antrectomía. Se observó resolución del sangrado en todos los casos, más allá de la terapéutica instituída.

The gastric antral vascular ectasia (GAVE) or watermelon stomach is an increasingly recognized cause of persistent upper gastrointestinal bleeding, which has typical endoscopic and histological findings. This disease is most frecuent in elderly women, and several associated conditions have been well established. Some patients with severe portal hypertensive gastropathy may have a GAVE like appearence. Nevertheless, a correct diagnosis is relevant in order to choose an appropiate treatment. The objective of the current study is to analize the clinical features and treatment of a group of patients with GAVE evaluated at our Institution. A review of the current literature was also performed. Six women and three men with GAVE were admitted at the Buenos Aires British Hospital between November 1998 and January 2004. Endoscopic biopsy was performed in eight patients and was consistent with GAVE in all cases. Four patients with chronic anaemia as unique manifestation were succesfully treated with iron supplements. Endoscopic treatment was performed in 4 patients, 3 of them were treated with bipolar electrocautery and 1 with argon plasma coagulation. An antrectomy was carried out in the ninth patient. The resolution of the bleeding was observed in all cases with the different therapeutics options used.

Vascular lesions of the gastrointestinal tract.

Vascular lesions of the gastrointestinal (GI) tract include arterio-venous malformations as angiodysplasia and Dieulafoy's lesion, venous ectasias (multiple phlebectasias and haemorroids), teleangiectasias which can be associated with hereditary hemorrhagic teleangiectasia (HHT), Turner's syndrome and systemic sclerosis, haemangioma's, angiosarcoma's and disorders of connective tissue affecting blood vessels as pseudoxanthoma elasticum and Ehlers-Danlos's disease. As a group, they are relatively rare lesions that however may be a major source of upper and lower gastrointestinal bleeding. Clinical presentation is variable, ranging from asymptomatic cases over iron deficiency anaemia to acute or recurrent bleeding that may be life-threatening. Furthermore, patients may present with other symptoms, e.g. pain, dysphagia, odynophagia, the presence of a palpable mass, intussusception, obstruction, haemodynamic problems resulting from high cardiac output, lymphatic abnormalities with protein loosing enteropathy and ascites, or dermatological and somatic features in syndromal cases. Diagnosis can usually be made using endoscopy, sometimes with additional biopsy. Barium radiography, angiography, intraoperative enteroscopy, tagged red blood cell scan, CT-scan and MRI-scan may offer additional information. Treatment can be symptomatic, including iron supplements and transfusion therapy or causal, including therapeutic endoscopy (laser, electrocautery, heater probe or injection sclerotherapy), therapeutic angiography and surgery. The mode of treatment is of course depending on the mode of presentation and other factors such as associated disorders. If endoscopic or angiographic therapy is impossible and surgical intervention not indicated, pharmacological therapy may be warranted. Good results have been reported with different drugs, albeit most of them have not been tested in large trials.

Watermelon stomach--an unusual cause of recurrent upper gastrointestinal bleeding in a uremic patient receiving estrogen-progesterone therapy: case report.

A 50-year-old woman who had been on maintenance hemodialysis for 5 years developed severe anemia resistant to treatment with iron supplements and erythropoietin 4 months prior to hospital admission. Her stool occult blood test was positive, and an initial panendoscopy revealed evidence of possible antral gastritis. However, repeated administration of sucralfate, H2 blockers and a proton pump inhibitor was not effective in preventing further gastrointestinal tract blood loss and subsequent refractory anemia. She required multiple blood transfusions and hospital admissions during this period. There was no obvious coagulopathy or thrombocytopenia. After her third admission, a second panendoscopy demonstrated the typical picture of watermelon stomach. A trial of hormone therapy with estrogen and progesterone increased the hemoglobin level within a month without further evidence of active gastrointestinal bleeding. From our experience with this case, we found that the diagnosis of antral vascular ectasia (watermelon stomach) with bleeding requires a high degree of clinical alertness and careful endoscopic examination. Estrogen and progesterone therapy may provide a good option for treating the disease in uremic patients without an obvious complication. To the best of our knowledge, this is the first report demonstrating the use of maintenance hormone therapy in a female uremic patient to successfully treat watermelon gastric bleeding.