Gastric Antral Vascular Ectasia: Can Radiofrequency Ablation Be the Answer?

Abstract

Background: Gastric antral vascular ectasia (GAVE) was first reported in 1953. The pathophysiology remains unknown. Conditions characteristically associated with GAVE are cirrhosis, autoimmune disorders e.g. scleroderma, chronic kidney disease, bone marrow transplantation. Surgical treatment options like gastric antrectomy have significant associated morbidity and mortality (Jensen et al, 2004). And while Argon plasma coagulation (APC) is an effective treatment, it requires frequent sessions and is rarely curative. (Tuveri et al, 2007). Case Report: A 62 year old white male was referred to our GI clinic for chronic iron deficiency anemia. His medical history included CAD s/p PCI, Cryptogenic cirrhosis s/p TIPS and he presented with multiple GI bleeds in the past. He underwent several endoscopies revealing portal hypertensive gastropathy, grade II esophageal varices and bleeding GAVE lesions. APC was performed twice at outside facilities for GAVE and symptomatic anemia. On evaluation, patient denied overt bleeding. Examination revealed anicteric sclera with pale conjunctivae. Abdomen was soft and distended with hepatosplenomegaly and 1+ pitting leg edema. Laboratory data revealed iron deficiency with Hb 10gm/dl. Despite undergoing 8 APC sessions at our facility, he remained iron deficient and symptomatic from anemia, requiring repeated transfusions. As he was refractory to APC therapy, decision was made to proceed with Radio Frequency Ablation (RFA) with Halo 90. A total of 5 sessions over 1 year led to resolution of anemia and transfusion requirements (Details in Table 1). Discussion: GAVE is an uncommon etiology of upper GI bleeding. These patients usually present with iron deficiency anemia. Medical, surgical and endoscopic therapies have been proposed with varying results and APC is considered a good first line treatment (Sebastian et al, 2004). Data regarding the utility of RFA for GAVE is limited to a handful of cases refractory to APC (Gross et al, 2007). Our patient showed significant improvement in symptoms, anemia and transfusion needs. Prior to RFA, he required 80 units of blood transfusions over 2 years. Post RFA session 1, he required 2 units and has since been transfusion free for the last 2 years, with a significantly improved quality of life. Whether the improvement in anemia has a linear relationship with the number of RFA sessions remains unknown. Challenges remain in treating GAVE patients due to the rarity of this condition and the lack of available literature. We propose that RFA be considered a treatment option for patients who fail APC therapy.Table 44