An Atypical Appearance of Gastric Antral Vascular Ectasia (GAVE) with Complete Resolution after Liver Transplant

Abstract

Purpose: Gastric antral vascular ectasia (GAVE) is a rare cause of upper gastrointestinal bleeding in end-stage liver patients being considered for liver transplant, and can be difficult to recognize. The correct diagnosis has therapeutic implications for successful treatment of bleeding. A 56-yearold male with alcoholic cirrhosis, complicated by ascites and non-bleeding gastroesophageal varices, presented for liver transplant evaluation. The most severe manifestation of his cirrhosis was chronic blood loss anemia requiring transfusion of two units of blood every two weeks. He had melenic stools and required frequent hospital admissions for anemia. A pre-transplant esophagogastroduodenoscopy revealed gastroesophageal varices without stigmata of recent bleeding, diffuse GAVE in the antrum with some areas of active oozing, and a fleshy, nodular mass in the second part of the duodenum with thick folds of oozing, friable mucosa. The most active areas of bleeding were over this mass-like lesion. A biopsy of the mass showed vascular ectasias with thombosis, consistent with nodular GAVE in the duodenum. The patient had treatment with serial argon plasma coagulation, however still remained transfusiondependent. Six months after the diagnosis of GAVE, he underwent an orthotopic liver transplantation. After the immediate post-operative period, he was no longer transfusion dependent. An esophagogastroduodenoscopy performed a year after his transplant showed complete resolution of his antral GAVE, as well as complete resolution of his nodular, duodenal GAVE. The endoscopic appearances of GAVE have been described in literature as puctate-type vascular ectasias, which are more strongly associated with cirrhosis, as well as striped, erythematous lesions arranged radially from the pylorus, more commonly termed “watermelon stomach.” Both these presentations share the same histologic findings of mucosal capillary dilations, fibrin thrombi, and fibromusclar hyperplasia. In our patient, we present an atypical, nodular presentation of GAVE in the duodenum. Our case also highlights the resolution of GAVE in patients with liver disease after liver transplantation. The recognition of GAVE is necessary for successful treatment. GAVE-induced bleeding can be treated with thermal ablation or estrogen, and can be cured with liver transplantation; however, it has not been shown to be responsive to treatments with reduction in portal pressure.