Biopsies of the Nodules GAVE Us the Diagnosis

Abstract

Purpose: Purpose: To describe an underappreciated endoscopic appearance of a common disorder, gastric antral vascular ectasia (GAVE). Case Presentations: We describe the cases of 2 patients who have a nodular form of GAVE. Our first patient is a 51 year old man with a history of cirrhosis due to nonalcoholic steatohepatitis who presented with iron deficiency anemia. He underwent evaluation with esophagogastroduodenoscopy (EGD) and was found to have multiple medium-sized antral nodules and mild linear antral erythema. The nodules were biopsied and the histopathology showed GAVE. Our second patient is a 61 year old woman with a history of cirrhosis due to non-alcoholic steatohepatitis, complicated by a history of bleeding esophageal varices. She underwent evaluation with EGD for esophageal variceal surveillance and was found to have small esophageal varices, portal hypertensive gastropathy, and many antral nodules. The nodules were biopsied and the pathology showed GAVE. Of interest, she did not have any endoscopic evidence of GAVE other than the antral nodules. Discussion: GAVE is a well-established cause of iron deficiency anemia and rarely of overt upper GI bleeding. It is normally idiopathic, but can be associated with cirrhosis. It is defined histopathologically by vascular ectasias, spindle cell proliferation, thrombosis in venules and fibrohyalinosis. There are 2 classic endoscopic appearances of GAVE. The first is longitudinal red stripes in the antrum radiating proximally from the pylorus, which has been termed the “watermelon stomach”. The second is a punctate form that lacks the red stripes and is the more common form seen in association with cirrhosis. Nodular GAVE is a third phenotype of this disorder which is far less well-known and could easily be dismissed as a fundic gland or hyperplastic polyp, based only on the endoscopic appearance. Thus, taking biopsies of antral nodules is required to make the diagnosis. It is yet to be determined what level of bleeding risk is associated with nodular GAVE and whether the same therapeutic regimens are of value in this form of GAVE. Conclusion: Nodular GAVE is a third endoscopic variant of GAVE, which can only reliably be differentiated from other gastric nodules/polyps through biopsy.