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.

["Watermelon stomach" can be the cause of severe gastrointestinal bleeding]. / Masszív gastrointestinalis vérzést okozó "görögdinnyegyomor".

Irregular vascular dilatation in the antrum or the cardia of the stomach can be the cause of severe gastrointestinal bleeding. The first term for it - in the beginning of the 50's of the previous century - was GAVE (Gastric Antral Vascular Ectasia) since at that time no similar phenomenon had been registered before. A quarter of a century later, after publishing a few cases, a witty internist described it as "watermelon stomach" because the macroscopic picture is similarly looking as the aforesaid fruit's appearing. This rare condition occured in one of our patient with many comorbid diseases.

Segmental colitis caused by idiopathic myointimal hyperplasia of mesenteric veins

Diseases causing colonic ischemia may be mistaken with other causes of segmental colitis such as inflammatory bowel disease, especially in young patients. The authors present the case of a 47-year-old male with severe proctosigmoiditis. Assessment excluded infectious causes, thrombophilia and systemic vasculitis. The initial histological specimen was suggestive of inflammatory bowel disease and therapy was initiated with intravenous steroids and, at day 5, infliximab, with no response. The patient was proposed for surgery. Pathological examination of the surgical specimen revealed an idiopathic myointimal hyperplasia of mesenteric veins, a rare entity exhibiting necrotizing phlebitis with rapid progression to segmental necrosis in the rectosigmoid colon. In this paper the authors discuss the differential diagnosis of proctosigmoiditis in young ages and the approach to this exceptionally rare ischemic entity (AU)

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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.

Causa inusual d'obstrucció gàstrica en el lactant: membrana antropilòrica / Causa inusual de obstrucción gástrica en el lactante: membrane antropilórica / Unusual cause of gastric outlet obstruction in infants; antral web

Introducció: la membrana antropilòrica (MA) és una alteració congènita de baixa incidència i difícil diagnòstic per la seva semblança clinicoradiològica amb l'estenosi hipertròfica de pílor (EHP). La MA completa o parcial causa una obstrucció del buidament gàstric que provoca vòmits de repetició no biliosos, deshidratació, pèrdua de pes i alcalosi metabòlica hipoclorèmica. La radiografia d'abdomen mostra una dilatació gàstrica greu, i l'ecografia abdominal ens descarta l'EHP. Aleshores cal plantejar altres causes d'obstrucció a la sortida gàstrica en el lactant, com la MA. Cas clínic: es presenta el cas d'un lactant d'1 mes i 5 dies, sense antecedents obstètrics d'interès, que consulta per vòmits no biliosos, estancament ponderal i hipotonia de 24 hores d'evolució. Les exploracions complementàries fetes van ser normals, tret d'un lleu reflux gastroesofàgic, i es va descartar l'EHP per ecografia abdominal. Davant la sospita d'intolerància a proteïnes de llet de vaca es va fer un canvi de fórmula d'inici a fórmula elemental amb persistència de la clínica i instauració progressiva d'alcalosi metabòlica. Amb la sospita de MA, es va fer un segon estudi ecogràfic dirigit que mostrava un petit ressort antropilòric que es va confirmar en la fibrogastroscòpia, i es va diagnosticar una MA parcial. La resecció quirúrgica de la membrana va re-soldre la clínica. Comentaris: davant d'un lactant amb obstrucció gàstrica, i un cop descartada la causa més comú (EHP), cal pensar en la membrana antral com a possible etiologia, ja que si aquesta es confirma, el seu maneig quirúrgic és definitiu amb resolució clínica posterio

Introducción. La membrana antropilórica (MA) es una alteración de baja incidencia y difícil diagnóstico por el parecido clínico-radiológico con la estenosis hipertrófica de píloro (EHP). La MA completa o parcial causa una obstrucción en la salida gástrica produciendo vómitos de repetición no biliosos, deshidratación, pérdida de peso y alcalosis metabólica hipoclorémica. La radiografía de abdomen muestra una dilatación gástrica severa y la ecografía abdominal descarta la EHP. Es entonces cuando hemos de plantear otras causas de obstrucción de la salida gástrica en el lactante, como la MA. Caso clínico. Se presenta el caso de un lactante de 1 mes y 5 días, sin antecedentes obstétricos de interés, que consulta por vómitos no biliosos, estancamiento ponderal e hipotonía de 24 horas de evolución. Las exploraciones complementarias realizadas fueron normales, excepto un leve reflujo gastroesofágico, y se descartó la EHP por ecografía abdominal. Ante la sospecha de intolerancia a proteínas de leche de vaca se realizó un cambio de fórmula de inicio a fórmula elemental, con persistencia de la clínica e instauración progresiva de alcalosis metabólica. Con la sospecha de MA, se realizó un segundo estudio ecográfico dirigido que mostraba un pequeño resorte antropilórico que se confirmaba en la fibrogastroscopia, y se diagnosticó una MA parcial. Con la resección quirúrgica de la membrana se resolvió la clínica. Comentarios. Ante un lactante con obstrucción gástrica, y una vez descartada la causa más común (EHP), se ha de pensar en la membrana antral como posible etiología, ya que si esta se confirma, su manejo quirúrgico es definitivo con la resolución clínica posterior (AU)

Introduction. The antral web (AW) is a disorder of low incidence and difficult diagnosis despite its similar clinical and radiological findings to hypertrophic pyloric stenosis (HPS). Complete or partial AW cause gastric outlet obstruction with persistent non-bilious vomiting, dehydration, weight loss, and hypochloremic metabolic alkalosis. Abdominal radiograph shows severe gastric dilatation; however, the normal abdominal ultrasound ruling out HPS should raise the suspicion of other causes of gastric outlet obstruction, such as AW. Case report. We report a case of a one-month and five days-old infant with no relevant obstetric history, who presented with a 24- hour history of non-bilious vomiting, lack of weight gain and hypotonia. Diagnostic studies suggested mild gastroesophageal reflux, and an abdominal ultrasound ruled out HPS. The diagnosis of intolerance to cow’s milk protein was first considered, and elemental formula was started without improvement. Suspecting AW, a repeat abdominal ultrasound showed a small prepyloric spring. Gastroscopy confirmed the diagnosis of partial AW, and surgical resection of the membrane resulted in resolution of the symptoms. Comments. In the presence of an infant with gastric outlet obstruction syndrome, and after the most common cause (HPS) has been ruled out, the diagnosis of AW should be considered. Surgery is curative (AU)

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.

Radiofrequency ablation of treatment-refractory gastric antral vascular ectasia (GAVE).

Gastric antral vascular ectasia (GAVE) is a rare but an important cause of gastrointestinal bleeding and anemia. Endoscopic ablation is usually successful, but treatment-refractory cases occur. We have used radiofrequency ablation (RFA) with the HALO device in these cases with positive results. Nine patients (5 female patients) with refractory GAVE were treated with RFA. Four had GAVE associated with cirrhosis, 4 had renal insufficiency, and 1 had both cirrhosis and renal insufficiency. Patients had received multiple endoscopic treatments before undergoing RFA over a period of up to 2 years (median 4; range, 2 to 15 y). A total of 2 to 6 (median 3) RFA sessions were performed until GAVE eradication. Endoscopic ablation was achievable in all patients. There were no complications of the treatments. Seven of the 9 patients had sustained response to RFA over a median follow-up of 11 months (range, 6 to 21 mo).