Pharmacotherapy for the Treatment of Gastric Antral Vascular Ectasia: A Narrative Review.

Gastric antral vascular ectasia (GAVE) is an uncommon clinical entity leading to recurrent gastrointestinal bleeding. There is no consensus regarding treatment of GAVE. Endoscopic therapy is the preferred treatment option, but has a fairly high recurrence rate. Surgical resection can completely resolve GAVE, but is invasive with a relatively high risk of postoperative complications. Recently, the role of pharmacotherapy for GAVE has been recognized. However, the evidence is limited to scattered case reports or small case series. This review comprehensively summarizes the efficacy and side effects of drugs commonly used for the treatment of GAVE, including octreotide, cyproheptadine, cyclophosphamide, prednisolone, estrogen-progesterone, thalidomide, bevacizumab, and tranexamic acid.

Intravenous Cyclophosphamide for Gastric Antral Vascular Ectasia Associated with Systemic Sclerosis Refractory to Endoscopic Treatment: A Case Report and Review of the Pertinent Literature.

Gastric antral vascular ectasia (GAVE) is a rare cause of chronic gastric hemorrhaging and iron deficiency anemia and is characterized by a distinctive endoscopic appearance. The main treatment of GAVE is endoscopic; however, medication is necessary in refractory cases. We herein report a 69-year-old woman with systemic sclerosis (SSc) who developed recurrent severe anemia after endoscopic treatment of GAVE that was successfully managed using intravenous cyclophosphamide (IVCY). The recurrence of GAVE after discontinuation of IVCY was successfully managed using a combination of IVCY and endoscopic treatment, without blood transfusion. Long-term IVCY may be indicated for refractory GAVE associated with SSc.

Antral mucosal perfusion is not increased in GAVE.

OBJECTIVES: Although a common cause of intestinal blood loss, the pathophysiology of gastric antral vascular ectasia (GAVE) is not well understood. We aimed to evaluate gastric antral and body mucosal flow in GAVE patients compared to a control population using laser Doppler flowmetry. METHODS: 27 patients with GAVE and 11 control patients without GAVE were evaluated using an endoscopic LDF probe. The probe was placed in the gastric antrum and body in order to calculate standardized mucosal flow rates recorded as perfusion units (PU). RESULTS: Despite its hyperemic appearance and propensity to bleed, antral blood flow was not increased in GAVE: 115.5 PU (IQR: [94.4, 135.9 PU]) in GAVE versus 123.7 PU (IQR: [109.7, 186.5 PU]) in controls. There was a significant gradient between the gastric body and antral blood flow in GAVE (p < 0.001) that was not evident in controls. CONCLUSION: These results indicate that antral mucosal blood flow is not increased in GAVE despite its grossly hyperemic appearance. A mild but statistically significant gradient was noted between the gastric antrum and body in patients with GAVE compared to controls. The pathophysiological significance of this finding is uncertain.

Vascular-targeted photodynamic therapy of gastric antral vascular ectasia (GAVE).

BACKGROUND AND STUDY AIM: Vascular-targeted photodynamic therapy (V-PDT) has been used for several benign vascular diseases. The aim of this pilot study was to demonstrate the potential benefits of VPDT in the treatment of gastric antral vascular ectasia (GAVE). PATIENTS AND METHODS: Data from patients with GAVE (n=5) who underwent endoscopic V-PDT were analyzed retrospectively. Pre- and post-V-PDT clinical and endoscopic features, hemoglobin levels, and transfusion requirement were compared. RESULTS: The five GAVE patients received one to four sessions of V-PDT. The hemoglobin levels of all five patients increased steadily following V-PDT. Within 6-48months of follow-up, gastrointestinal bleeding and melena disappeared in all five patients and none of the patients needed a transfusion. Endoscopy examinations showed that the dilated vessels had disappeared without scar formation. No significant side effects or adverse reactions were reported. CONCLUSION: This preliminary study indicates the good selectivity, safety, and efficacy of V-PDT in the treatment of patients with GAVE. Larger prospective studies are needed to further confirm the feasibility of using V-PDT to treat patients with GAVE.

Gastric Antral Vascular Ectasia during the Treatment of Chronic Myelogenous Leukemia with Imatinib Mesylate.

This report describes three patients with chronic myelogenous leukemia who developed gastric antral vascular ectasia (GAVE) during treatment with imatinib mesylate (IM). Cessation and/or switching from IM to nilotinib resulted in the alleviation of gastrointestinal (GI) bleeding and ectatic lesions. Furthermore, GI bleeding recurred after the re-administration of IM in one patient. Thus, we consider that the occurrence of GAVE in our patients was induced by IM. Although the precise mechanism of IM-GAVE is not understood, all patients took at least 400 mg/day of IM at the onset of GAVE. Thus, higher doses of IM (≥400 mg/day) may be a risk factor for IM-GAVE.

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.

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.

Simultaneous occurrence of gastric antral vascular ectasia and protein-losing enteropathy in chronic graft-versus-host disease.

Gastric antral vascular ectasia (GAVE) leading to upper gastrointestinal bleeding is a heterogeneous disorder that is not commonly recognized in hematopoietic stem cell transplantation (HSCT). Protein-losing enteropathy (PLE) is noted as another gastrointestinal complication in the context of chronic graft-versus-host disease (GVHD) after HSCT. The possibility of a relationship between these two distinct gastrointestinal disorders, however, remains obscure. A 6-year-old boy with acute myelogenous leukemia developed severe hematemesis 4 months after myeloablative HSCT from a human leukocyte antigen-matched sibling donor. The diagnosis of GAVE was made by upper endoscopy and histological examination. The patient simultaneously developed frequent diarrhea and significant hypoproteinemia, consistent with a diagnosis of PLE. This co-occurrence of GAVE and PLE against a background of chronic GVHD was successfully treated with cyclosporin A and prednisolone. To our knowledge, this is the first report of GAVE concurrent with PLE following HSCT. The possible association of GAVE and PLE in chronic GVHD is discussed.

Improvement of severe systemic sclerosis-associated gastric antral vascular ectasia following immunosuppressive treatment with intravenous cyclophosphamide.

OBJECTIVE: We describe 3 patients with systemic sclerosis (SSc) with severe, transfusion-dependent gastric antral vascular ectasia (GAVE) refractory to laser ablation who showed remarkable clinical and endoscopic improvement following intravenous (IV) pulse cyclophosphamide (CYC) treatment. METHODS: Review of clinical records and upper gastrointestinal endoscopy images from 3 patients with SSc and severe GAVE before and after treatment with IV pulse CYC. RESULTS: IV CYC was followed by improvement and stabilization of hemoglobin levels, and marked reduction in blood transfusion requirements and the number and frequency of endoscopic laser treatments. CONCLUSION: IV pulse CYC immunosuppression was followed by remarkable clinical and endoscopic improvement of SSc-associated GAVE.

Seguimiento a largo plazo de pacientes con ectasia vascular del antro gástrico tratados mediante coagulación con argón plasma / Long-term follow-up of patients with gastric antral vascular ectasia treated with argon plasma coagulation

Fundamento y objetivo: La APC (argon plasma coagulation coagulación con argón plasma ) es actualmente el método más utilizado para tratamiento endoscópico de la GAVE (gastric antral vascular ectasia ectasia vascular antral gástrica ) por su fácil uso y sus bajas tasas de complicaciones. El objetivo de este trabajo fue analizar la efectividad y la seguridad de la APC en el tratamiento de la GAVE. Material y método: Se revisaron retrospectivamente los pacientes con GAVE tratados con APC y con seguimiento superior a 24 meses. Resultados: Se incluyó a 18 pacientes (edad media de 67,16 DE: 13,53 años), 11 de éstos eran mujeres. Cinco pacientes se presentaron como hemorragias agudas y 13 como anemia crónica. La eliminación de la GAVE se consiguió en una media de 3,38 de 1 a 4 sesiones por paciente. No hubo complicaciones mayores. Hubo 5 hemorragias leves y 11 epigastralgias autolimitadas durante el tratamiento. En 2 pacientes con hipergastrinemia basal se desarrollaron pólipos hiperplásicos. Siete pacientes (39%) recidivaron: 3 hemorragias antes de 12 meses y 4 anemias después de 12 meses. No se encontraron diferencias entre los pacientes que presentaron recidivas y los que no presentaron recidivas. Conclusión: La APC es una técnica efectiva y segura en el tratamiento de la GAVE. Las recidivas clínicas y endoscópicas aumentan con el paso del tiempo, por lo que es necesaria la monitorización clínica y analítica de estos pacientes (AU)

Background and objective. Due to its easy use and low complication rates, argon plasma coagulation (APC) it is most common method of endoscopic treatment for gastric antral vascular ectasia (GAVE). We analyze both the long term effectiveness of APC for the treatment of GAVE and its side effects. Material and methods: A retrospective review of GAVE patients treated with APC and followed up for a minimum of 24 months was done. Results: Eighteen patients (mean age 67,16±13,53; 11 women) were included. Five initially presented with acute bleeding and 13 with anemia. GAVE eradication was achieved over 3.38±1,4 sessions per patient. There were no major complications. Five patients had mild bleeding and 11 complained of abdominal pain, that was self-limited during treatment. Seven patients relapsed (39%); 3 of them with melenae and 4 with anemia. Two patients with hypergastrinemia developed hyperplastic polyps. No differences were found between relapsers and non-relapsers. Conclusions: APC is a safe and effective technique for the treatment of GAVE. The recurrence rates increase gradually over time. Early action on recurrence would require improved clinical follow-up and blood test monitoring (AU)

Treatment of chronic transfusion-dependent gastric antral vascular ectasia (watermelon stomach) with thalidomide.

Gastric antral vascular ectasia (GAVE) is a rare condition causing chronic GI blood loss that often proves difficult to treat. Many patients require repeated transfusions despite best efforts made with endoscopic and pharmacological therapies. We attempted to manage a patient with endoscopic resistant GAVE with Thalidomide. Within 3 months the patient became transfusion independent and has maintained an adequate haemoglobin for 9 months on the Thalidomide therapy.

Portal hypertensive gastropathy.

Portal hypertensive gastropathy (PHG) is the term used to describe the endoscopic appearance of gastric mucosa seen in patients with cirrhotic or non-cirrhotic portal hypertension with a characteristic mosaic-like pattern with or without red spots. The prevalence of PHG varies from 50% to 98%, this variation of the prevalence being perhaps related to patient selection, inter- and intra-observer variation and absence of uniform criteria and classification. About 8% of the upper digestive hemorrhages in the cirrhotic patients are secondary to PHG. There is no general consensus on the endoscopic classification of PHG (the most New Italian Endoscopy Club). The exact pathogenesis of PHG is not completely understood, but the portal hypertension is the main factor involved in its development and not the severity of the hepatic disease. Gastric Antral Vascular Ectasia (GAVE) is a term used for the typical endoscopic findings of red stripes, separated by normal mucosa, most frequently seen in the gastric antrum or proximal stomach. Current therapy of PHG includes beta blockers, somatostatin and derivates, endoscopic and surgical methods including hepatic transplantation.

[Treatment of chronic transfusion-requiring watermelon stomach with oral contraceptives]. / Behandling af kronisk transfusionskraevende watermelon stomach med p-piller.

Gastric antral vascular ectasia (GAVE), watermelon stomach, is a rare cause of upper gastrointestinal bleeding. We describe two male patients with GAVE in whom endoscopic argon beaming had no effect, but who were treated successfully with 1 mg of norethisterone and 30 mg of ethinyloestradiol daily.