Gastric Vascular Ectasia Research Articles

Gastric Bleeding in Stem Cell Transplantation: A Focus on Gastric Vascular Ectasia Under Post-Transplant Cyclophosphamide, Sirolimus, and Mycophenolate Mofetil Prophylaxis

Gastrointestinal bleeding (GIB) is a serious complication following allogeneic hematopoietic stem cell transplantation (HSCT), with limited data on its incidence and characteristics, particularly for upper gastrointestinal bleeding (UGIB) of gastric origin. We aimed to evaluate the incidence, clinical, endoscopic, and histopathologic features, and outcomes of UGIB, with a focus on gastric vascular ectasias (GVEs) in patients undergoing HSCT with graft-versus-host disease (GVHD) prophylaxis using post-transplant cyclophosphamide (PTCY), sirolimus or calcineurin inhibitors, and mycophenolate mofetil. This retrospective, single-center study included all adult patients who underwent allogeneic HSCT at a single institution between January 2017 and December 2023. Data were collected on transplant procedures, complications, and GIB incidents, with UGIB cases undergoing endoscopic and histologic examination. Out of 559 patients, 38 (6.6%) experienced UGIB, with 27 cases (70%) attributed to GVE. GVE typically presented as melena or hematemesis at a median time of 68 days (range, 29-125) after transplant. Endoscopy revealed diffuse oozing from gastric antral mucosa without distinct lesions, while histology showed vascular congestion and mild foveolar hyperplasia. The 6-month cumulative incidence of GVE was 5.1%. Older age (≥60 years) and diagnosis of myelodysplastic/myeloproliferative neoplasm were significant risk factors. All cases resolved with no attributable mortality with supportive measures including transfusions, proton-pump inhibitors, and sirolimus withdrawal in some cases. GVE is a notable cause of UGIB in HSCT recipients on PTCY-based GVHD prophylaxis, presenting significant morbidity but favorable outcomes with appropriate management. The potential role of sirolimus and conditioning agents in GVE pathogenesis warrants further investigation.

A133 PORTAL VENOUS STENTING FOR THE TREATMENT OF NON-CIRRHOTIC PORTAL HYPERTENSION-RELATED GASTRIC ANTRAL VASCULAR ECTASIA: A CASE REPORT

Abstract Background Pancreatic and hepatobiliary cancers account for 15-24% of extrahepatic portal hypertension. Treating portal hypertensive bleeding associated with these tumors has been challenging with the delayed effect of chemoradiation and patients with active bleeding being unfit for such therapies. Portal vein stenting has been described in the literature for the treatment of variceal bleeding in such patients. We present the first report of its use for the successful treatment of refractory gastric vascular ectasia (GAVE)-related bleeding. Purpose To review portal vein stenting as a treatment for non-cirrhotic portal hypertension-related GAVE bleeding. Method Chart review was performed with the patient's informed consent. Result(s) A 53-year-old female patient with locally invasive pancreatic cancer presented with one week of melena and presyncope. She had a history of gastroesophageal reflux disease. Her tumor encased the celiac trunk, hepatic and splenic arteries, and abutted the superior mesenteric artery. She had been treated with chemotherapy and radiation. On examination, she was afebrile, blood pressure was 132/87, pulse 110 beats/min, and oxygen saturation 99% on room air. Her abdomen was soft and non-tender. Her hemoglobin was 63 g/L, which represented a 64-point drop over 4 months, leukocytes 4.5 x109/L, platelets 238 x109/L, INR 1.1 and normal electrolytes and creatitine. Alkaline phosphatase was 399 U/L, aminotransferases normal, albumin 38 g/L and total bilirubin 6 umol/L. She was started on pantoprazole and octreotide. On admission, gastroscopy revealed copious blood in the stomach with no clear source despite gastric lavage; hemospray was applied. Given persistent bleeding, repeat gastroscopy the following day revealed 4 columns of Baveno grade III esophageal varices with no high-risk stigmata, as well as severe portal hypertensive gastropathy and GAVE. Argon plasma coagulation and esophageal banding were performed. Over the next month, she continued to have maroon-colored stools. CT angiogram revealed portal vein occlusion and contrast extravasation within the gastric lumen, in keeping with her known gastric antral bleed, with no evidence of lower gastrointestinal bleeding. She had 5 further gastroscopies where APC and GAVE banding were performed. Despite that, she developed hematemesis. Interventional radiology was consulted and performed transhepatic portal venous recanalization, angioplasty and stenting using a 10mm x 60mm self expandable nitinol stent from the superior mesenteric vein to the main portal vein. After stenting, previously seen collateral veins and cavernous transformation were significantly reduced on angiography. She was started on clopidogrel to maintain stent patency. Two days following stent insertion, she stopped clinically bleeding and her hemoglobin stabilized. She was discharged home one month later. Conclusion(s) In patients with GAVE-related bleeding refractory to standard therapeutics, portal venous stenting is possibly an effective treatment modality. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Early Gastric Cancer Arising From Hyperplastic Polyps After Argon Plasma Coagulation for Gastric Vascular Ectasia

Early Gastric Cancer Arising From Hyperplastic Polyps After Argon Plasma Coagulation for Gastric Vascular Ectasia

Endoscopic eradication of nodular gastric vascular antral ectasia by using band ligation after argon plasma coagulation

Gastric antral vascular ectasia (GAVE) is an important cause of gastro-intestinal bleeding. The most common clinical presentation of GAVE is chronic occult bleeding that leads to symptomatic iron deficiency anemia, but some cases could present with acute massive bleeding. Frequently, patients are dependent by iron suplimentation, or in severe cases even blood transfusions. Endoscopic therapy is frequently necessary in acute or chronic blood loss. Over the past several years, treatment for GAVE has continued to evolve as the number of available effective therapeutic interventions has increased. These included: YAG laser, argon plasma coagulation (APC), endoscopic band ligation, cryotherapy and surgical anterectomy. Argon plasma coagulation is the most commonly used technique, but has been associated with several complications like sepsis, post-APC bleeding, gastric outlet obstruction and increased incidence of hyperplastic polyps. Endoscopic band ligation (EBL), a mechanical procedure, has been reported in the past years as an effective salvage therapy for GAVE that is refractory to other approaches, or even as the first line treatment. We present a case of nodular GAVE treated succesfully with endoscopic band ligation after unsuccesufull sessions with argon plasma coagulation.

Mo1367 Utility of Through the Scope (TTS) Radiofrequency Ablation in the Management of Gastric Vascular Antral Ectasia (GAVE)

Gastric antral vascular ectasia (GAVE) is an infrequent cause of chronic anemia in patients with cirrhosis or autoimmune diseases, especially scleroderma. Radiofrequency ablation (RFA) utilizing the Halo90 device has been successfully used in treating refractory GAVE. The through the scope (TTS) catheter device RFA technique can similarly be useful owing to its design, size and easy maneuverability; however, data on this technique remains scant.

Sa1681 Long Term Treatment Outcome of Patients With Gastric Vascular Ectasia Treated With Argon Plasma Coagulation

Sa1681 Long Term Treatment Outcome of Patients With Gastric Vascular Ectasia Treated With Argon Plasma Coagulation

Cyanoacrylate spray for treatment of difficult-to-control GI bleeding

Although endoscopic therapy is highly effective for control of GI bleeding, a small proportion of patients experience persistent bleeding and may require radiologic or surgical intervention. Experience with cyanoacrylate spray for treatment of difficult-to-control GI bleeding is limited. To evaluate the efficacy and safety of an endoscopic cyanoacrylate spray technique for treatment of difficult-to-control GI bleeding. Case series. Two tertiary-care centers. This study involved consecutive patients with overt GI bleeding who were treated with n-butyl-2-cyanoacrylate spray during endoscopy for persistent bleeding despite conventional hemostatic therapies. Cyanoacrylate spray. Hemostasis, rebleeding, adverse events, and technical failure associated with cyanoacrylate spray. Five patients were treated with cyanoacrylate spray during endoscopy for persistent bleeding (duodenal ulcer in 3, gastric vascular ectasia in 1, rectal postpolypectomy bleeding in 1) after failed conventional therapies. Immediate hemostasis and technical success were achieved in all patients. At a median follow-up of 42 days (range 38-120 days), 2 patients developed recurrent bleeding. One patient experienced rebleeding 2 days after the procedure, subsequently requiring radiographic intervention and surgery. Another patient had recurrent bleeding from a different bleeding source 18 days after the procedure. No adverse events attributed to the cyanoacrylate spray were observed. Small number of patients. In patients with difficult-to-control GI bleeding failing conventional endoscopic therapies, cyanoacrylate spray was effective in achieving immediate hemostasis. Prospective studies with a larger number of patients to evaluate the role of the cyanoacrylate spray technique during endoscopy for GI bleeding are needed.

Gastric antral polyps: a manifestation of portal hypertensive gastropathy

Editor, Gastric mucosal lesions are common in portal hypertension, occur in up to 65 % of cirrhotics, and represent an important cause of gastrointestinal (GI) blood loss. They include portal hypertensive gastropathy (PHG) and gastric vascular ectasia (GVE) [1]. The diagnosis of PHG is based on the presence of a characteristic mosaic-like pattern of the gastric mucosa on endoscopic examination. Superimposed on this mosaiclike pattern may be red spot lesions that usually are greater than 2 mm in diameter [1]. Polypoidal lesions in portal gastropathy on endoscopy have been described in two studies [2, 3]. We present eight cases of cirrhosis and portal hypertension with severe PHG and antral polyps. We prospectively evaluated patients admitted to our department, with a diagnosis of cirrhosis, between January 2011 and March 2012 and performed upper GI endoscopy. Clinical, laboratory, endoscopy, and histology data of these patients were analyzed. During the study period, 786 patients with cirrhosis underwent upper GI endoscopy. Of these, eight (1.01 %, seven male) patients, ranging in age from 43 to 70 years, had portal hypertensive polyps. Seven patients had alcoholic cirrhosis, and one patient had hepatitis B-related cirrhosis, all of Child’s C class. The CTP score ranged from 8 to 13 and model for end-stage liver disease ranged from 9 to 21. None had hepatocellular carcinoma or portal vein thrombosis. Six patients had history of upper GI bleed and had undergone esophageal variceal ligation previously. Endoscopy in all eight patients showed multiple antral polyps two to five in number and with size ranging from 0.5 to 1 cm. All patients had associated severe PHG. Two of the six patients with upper GI bleed continued to have drop in hemoglobin and stool occult blood positivity despite eradication of varices, and one had an overt bleeding polyp on endoscopy shown in Fig. 1d. These patients underwent endoscopic polypectomy once the platelet count was corrected to more than 50,000/mm and prothrombin time was corrected with plasma. On follow up, none of the patients had a drop in hemoglobin or rebleed. Small-bowel evaluation was not done in any of these patients as they did not have a drop in hemoglobin after polypectomy. Biopsy of polyps showed elongation, tortuosity, and dilatation of gastric foveolae with the surrounding stroma showing edema, mild inflammation, and scattered smooth muscle bundles. Numerous proliferating capillaries were present in the subepithelial tissue differentiating these polyps from usual hyperplastic polyps. There were no areas of dysplasia. Rapid urease test was negative, and histology and special stains did not reveal Helicobacter pylori in any of the patients. Cirrhotics with portal hypertensive polyps did not differ from cirrhotics without portal hypertensive polyps with regard to etiology or severity of cirrhosis, duration of illness, or past history of variceal eradication. Gastroscopy in PHG shows a mosaic-like pattern of the gastric mucosa with mild and superimposed discrete cherry red spots, fine pink speckling, or scarlatina-type rash when severe [1]. Biopsies show vascular ectasia and congestion in the mucosal layer without a significant degree of inflammatory infiltrate [4, 5]. Perturbations in the tissue levels of TNF-α, prostaglandins, endothelin, and nitric oxide/peroxynitrite may participate in the vascular congestion and mucosal damage characteristic of PHG [4, 5]. Some patients with cirrhosis and portal hypertension have GVE [5]. The entity is characterized by aggregates of ectatic vessels that C. Panackel (*) :H. Joshy :B. Sebastian : S. K. Mathai Department of Gastroenterology, Medical Trust Hospital, Kochi 682 016, India e-mail: charlespanackel@hotmail.com

Gastric Antral Vascular Ectasia and Its Clinical Correlates in Patients with Early Diffuse Systemic Sclerosis in the SCOT Trial

To describe the prevalence and clinical correlates of endoscopic gastric antral vascular ectasia (GAVE; "watermelon stomach") in early diffuse systemic sclerosis (SSc). Subjects with early, diffuse SSc and evidence of specific internal organ involvement were considered for the Scleroderma: Cyclophosphamide Or Transplant (SCOT) trial. In the screening procedures, all patients underwent upper gastrointestinal endoscopy. Patients were then categorized into those with or without endoscopic evidence of GAVE. Demographic data, clinical disease characteristics, and autoantibody data were compared using Pearson chi-square or Student t tests. Twenty-three of 103 (22.3%) individuals were found to have GAVE on endoscopy. Although not statistically significant, anti-topoisomerase I (anti-Scl70) was detected less frequently among those with GAVE (18.8% vs 44.7%; p = 0.071). Similarly, anti-RNP antibodies (anti-U1 RNP) showed a trend to a negative association with GAVE (0 vs 18.4%; p = 0.066). There was no association between anti-RNA polymerase III and GAVE. Patients with GAVE had significantly more erythema or vascular ectasias in other parts of the stomach (26.1% vs 5.0%; p = 0.003). Endoscopic GAVE was present on screening in almost one-fourth of these highly selected patients with early and severe diffuse SSc. While anti-Scl70 and anti-U1 RNP trended toward a negative association with GAVE, there was no correlation between anti-RNA Pol III and GAVE. Patients with GAVE had a higher frequency of other gastric vascular ectasias outside the antrum, suggesting that GAVE may represent part of the spectrum of the vasculopathy in SSc.

Long-term efficacy of endoscopic coagulation for different types of gastric vascular ectasia

To examine the long-term therapeutic efficacies of endoscopic cauterization for gastric vascular ectasia, according to the type of lesion. Thirty-eight patients with hemorrhagic gastric vascular ectasia (VE) were treated by endoscopic cauterization: 13 by heater probe coagulationand 25 by argon plasma coagulation. Depending on the number of lesions, 14 and 24 patients were classified into localized VE (≤ 10; LVE) and extensive VE (> 10; EVE), respectively. The patients were followed-up by repeated endoscopic examinations after the therapy, and the incidences of VE recurrence and re-bleeding from the lesions were evaluated. Although the VE lesions disappeared initially in all the patients after the therapy, the recurrence of VE developed in 25 patients (66%) over a mid-term observation period of 32 mo, and re-bleeding occurred in 15 patients (39%). The recurrence of VE was found in all patients with EVE, with re-bleeding occurring in 14 patients (58%). In contrast, only 1 patient (7%) with LVE showed recurrence of the lesions and complicating hemorrhage. Both the cumulative recurrence-free rates and cumulative re-bleeding-free rates were significantly lower in the EVE group than in the LVE group (P < 0.001 and P < 0.001, respectively). Moreover, the cumulative re-bleeding-free rate in the EVE group was 47.6% at 1 year and 25.4% at 2 years in patients with chronic renal failure, which were significantly lower than the rates in the patients without chronic renal failure (83.3% and 74.1%, respectively) (P < 0.05). The recurrence of VE and re-bleeding from the lesions was more frequent in the patients with EVE, especially in those with complicating renal failure.

The Use of Cyanoacrylate Spray in Difficult to Treat Acute Gastrointestinal Bleeding

Purpose: Although endoscopic therapy is highly effective in control of acute gastrointestinal bleeding (GIB), a small portion of patients who fail to achieve hemostasis may require interventional radiologic procedures or surgery with increased morbidity. Cyanoacrylate compound is a tissue adhesive used as a hemostatic agent for treatment of gastric varices and intraoperative bleeding, but data on spray application in acute GIB is limited. The aim of this study is to evaluate the efficacy and safety of cyanoacrylate spray in patients with difficult to treat acute GIB. Methods: Consecutive patients from July 2010 to May 2012 hospitalized at Riverside County Regional Medical Center and Loma Linda University Medical Center who required cyanoacrylate compound spray for treatment of GIB were identified from an internal endoscopic database. Cyanoacrylate spray technique was used after failure of conventional endoscopic treatments per discretion of the endoscopist. Using a 23 gauge sclerotherapy needle positioned 1 cm outside the tip of the endoscope, 0.5-4.0 ml of commercially available cyanoacrylate compound (butyl-2-cyanoacrylate) was sprayed over the bleeding site followed by a rapid normal saline flush to prevent congealing. Results: During the study period, four patients required cyanoacrylate spray for difficult to treat acute GIB (Table). Patient 1 presented with hematochezia and hemodynamic instability requiring 16 units of PRBC. Upper endoscopy showed active arterial bleeding from a duodenal ulcer base, despite blind epinephrine injection. Half ml of cyanoacrylate spray achieved hemostasis. However, due to limited experience with this technique, the patient underwent IR embolization despite lack of rebleeding. Patient 2 with history of Osler-Webber-Rendu Syndrome presented with melena due to multiple gastric vascular ectasias. One ml of cyanoacrylate spray achieved hemostasis. The patient had rebleeding after 18 days possibly from a different gastric vascular ectasia. Patient 3 on aspirin presented with hematochezia and hemodynamic instability after polypectomy. Half ml of cyanoacrylate spray achieved hemostasis. Patient 4 presented with melena and hemodynamic instability from a duodenal ulcer with arterial spurting requiring 8 units of PRBC. Four ml of cyanoacrylate spray achieved hemostasis. Repeat EGD next day revealed no active bleeding. No immediate or delayed complications were noted on the four patients at a median follow-up of 42 days (range, 28-120).Table: [1773]Conclusion: In patients with active GIB that is difficult to control with conventional endoscopic modalities, cyanoacrylate spray achieved 100% hemostasis. This novel technique is simple, safe, and efficacious and should be considered in the armamentarium in the treatment of GIB.

Pharmacotherapy of Gastric Vascular Ectasia: Systematic Evaluation of 49 Cases with Meta-Analysis

Pharmacotherapy of Gastric Vascular Ectasia: Systematic Evaluation of 49 Cases with Meta-Analysis

Non-variceal Gastrointestinal Bleeding in Patients with Liver Cirrhosis: A Review

Non-variceal gastrointestinal (NVGI) bleeding in cirrhosis may be associated with life-threatening complications similar to variceal bleeding. To review NVGI bleeding in cirrhosis. MEDLINE, Scopus, and ISI Web of Knowledge were searched, using the textwords "portal hypertensive gastropathy," "gastric vascular ectasia," "peptic ulcer," "Dieulafoy's," "Mallory-Weiss syndrome," "portal hypertensive enteropathy," "portal hypertensive colopathy," "hemorrhoids," and "cirrhosis." Portal hypertensive gastropathy (PHG) and gastric vascular ectasia (GVE) are gastric lesions that most commonly present as chronic anemia; acute upper GI (UGI) bleeding is a rare manifestation. Management of PHG-related bleeding is mainly pharmacological, whereas endoscopic intervention is favored in GVE-related bleeding. Shunt therapies or more invasive techniques are restricted in refractory cases. Despite its high incidence in cirrhotic patients, peptic ulcer accounts for a relatively small proportion of UGI bleeding in this patient population. However, in contrary to general population, the pathogenetic role of Helicobacter pylori infection remains questionable. Finally, other causes of UGI bleeding include Dieulafoy's lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids. However, the vast majority of studies are case reports and, therefore, the incidence, diagnosis, and risk of bleeding remain undefined. Endoscopic interventions, shunting procedures, and surgical techniques have been described in this setting. The data on NVGI bleeding in liver cirrhosis are surprisingly scanty. Large, multicenter epidemiological studies are needed to better assess prevalence and incidence and, most importantly, randomized studies should be performed to evaluate the success rates of therapeutic algorithms.

Nodules in antrum after variceal eradication a new finding in patients with portal hypertension

Portal hypertension is known to cause esophageal varices, gastric varices and portal hypertensive gastropathy (PHG). The prevalence of gastric varices and PHG is known to increase after eradication of esophageal varices. PHG includes the presence of a mucosal mosaic pattern, cherry red spots, and/or black-brown spots and gastric vascular ectasia (GAVE). Patients with portal hypertension in whom esophageal varices were eradicated were on follow up endoscopy for detection of recurrence of esophageal varices. Their status of PHG was assessed and patients antral nodules were enrolled. Twenty patients with antral nodules were identified over one year. Fifteen out of 20 patients had cirrhosis as etiology of portal hypertension, three had non-cirrhotic portal hypertension and two had extra-hepatic portal vein thrombosis. GAVE was seen more commonly (n=8, 40%) in patients with PHG with nodules. PHG with antral nodules is a novel endoscopic finding present both in cirrhotic and non-cirrhotic portal hypertension with unknown pathogenesis, and is seen more commonly in patients with eradicated varices who are on long-term follow up.

The Biopsy GAVE the Diagnosis

A 51-year-old man with nonalcoholic steatohepatitis (NASH) cirrhosis was evaluated for chronic iron deficiency anemia (hemoglobin, 7–8 g/dL). Occasional scant rectal bleeding could not account for the anemia. At esophagogastroduodenoscopy (EGD), many benign-appearing 3-mm antral nodules were seen as well as mild linear antral erythema (Figure A). No varices or other abnormalities were found. A 61-year-old woman with NASH cirrhosis underwent band ligation for bleeding esophageal varices. At follow-up EGD, there were small esophageal varices, portal hypertensive gastropathy, and many antral nodules (Figure B), but no active bleeding. There were no mucosal abnormalities such as red stripes or punctate erythema. A 58-year-old man with alcoholic cirrhosis had iron deficiency anemia and melena and required monthly blood transfusions. EGD showed antral nodules and punctate antral erythema in crops (Figure C) but no varices or other cause for blood loss. In each case, biopsies of the antral nodules showed the classic histologic features that define gastric antral vascular ectasia (GAVE), as illustrated: vascular ectasias (Figure D, arrow), hyperplastic foveolar (serrated) gastric epithelium (Figure E, arrow), thrombosis in venules (Figure F, arrow), fibrohyalinosis, and spindle-cell (myofibroblast) proliferation (not shown).1Ripoll C. Garcia-Tsao G. Management of gastropathy and gastric vascular ectasia in portal hypertension.Clin Liver Dis. 2010; 14: 281-294Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar GAVE commonly causes iron deficiency anemia and occasionally overt upper gastrointestinal bleeding. The cause of GAVE is unknown. Approximately 30% of GAVE patients have cirrhosis,2Selinger C.P. Ang Y.S. Gastric antral vascular ectasia (GAVE): an update on clinical presentation, pathophysiology and treatment.Digestion. 2008; 77: 131-137Crossref PubMed Scopus (97) Google Scholar although portal hypertension is not part of the pathogenesis.1Ripoll C. Garcia-Tsao G. Management of gastropathy and gastric vascular ectasia in portal hypertension.Clin Liver Dis. 2010; 14: 281-294Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 3Spahr L. Villeneuve J.P. Dufresne M.P. et al.Gastric antral vascular ectasia in cirrhotic patients: absence of relation with portal hypertension.Gut. 1999; 44: 739-742Crossref PubMed Scopus (144) Google Scholar Other associations include scleroderma, chronic renal failure, and bone marrow transplantation.4Burak K.W. Lee S.S. Beck P.L. Portal hypertensive gastropathy and gastric antral vascular ectasia (GAVE) syndrome.Gut. 2001; 49: 866-872Crossref PubMed Scopus (135) Google Scholar GAVE classically appears endoscopically as either (1) longitudinal red stripes in the antrum radiating proximally from the pylorus, the so-called watermelon stomach, or (2) punctate erythema in crops that is common in patients with cirrhosis (Figure C). We describe a nodular form of GAVE as a third endoscopic phenotype of this disorder that shares the classic histologic features with the striped and punctate forms of GAVE. Nodular GAVE could easily be dismissed as fundic gland, inflammatory, or hyperplastic polyps, on the basis only of endoscopic appearances. Biopsy of the antral nodules is required to make the diagnosis. Typically, GAVE is treated with argon plasma coagulation to prevent or treat bleeding,5Fuccio L. Zagari R.M. Serrani M. et al.Endoscopic argon plasma coagulation for the treatment of gastric antral vascular ectasia-related bleeding in patients with liver cirrhosis.Digestion. 2009; 79: 143-150Crossref PubMed Scopus (35) Google Scholar but unknown are the level of bleeding risk in nodular GAVE and whether thermocoagulation management is of value. In summary, we describe a third nodular variant of GAVE that can only reliably be differentiated from other gastric nodules/polyps seen endoscopically by biopsy. The prevalence and clinical course of this nodular variant have yet to be determined, because this form of GAVE has not previously been well appreciated.

Gastrointestinal Manifestations of Scleroderma: Recent Progress in Evaluation, Pathogenesis, and Management

Gastrointestinal (GI) involvement is frequent in scleroderma (systemic sclerosis [SSc]) and is the most frequent internal complication of the disease. Patients with GI involvement have impaired quality of life, and their prognosis may be one of severe impairment. Unfortunately, GI involvement is often noticed when severe complications have already occurred, is irreversible, and is difficult to manage. The past 2 to 3 years have been rich in exciting studies that we hope will help identify, prevent, treat, and monitor disease progression. Recent studies on the pathophysiology of GI tract disease could lead to advances in the treatment of GI tract involvement. The importance of treating gastroesophageal reflux (GER) has been reinforced by studies showing GER damage in almost all SSc patients, and the fact that GER damage is reversible if early treatment with proton pump inhibitors is introduced. Moreover, recent data showing a link between GER and interstitial lung disease in SSc underscore the importance of aggressive GER treatment in SSc patients. A novel lung pattern possibly related to GER also has been described. New, exciting data on gastric vascular antral ectasia have been published. Finally, malnutrition in SSc patients has been highlighted, and anorectal involvement has been emphasized.

Gastroesophageal junction tear from HALO 90®System: A case report

Gastric antral vascular ectasia often results in chronic gastrointestinal bleeding with few options for effective treatment. The Halo(®) 90 system has been newly approved for this indication. A 56 year old male with ETOH cirrhosis and gastrointestinal bleeding from gastric vascular ectasia presented for endoscopy with Halo(®) 90 radiofrequency ablation. Over the past two years he had undergone multiple bipolar electric coagulation and argon plasma coagulation treatments. Despite this therapy, he con-tinued to receive monthly blood transfusions. We therefore opted to treat the vascular anomalies with the Halo(®) 90 system utilizing radiofrequency ablation. Upon withdrawal of the endoscope post procedure, mild resistance and bleeding was noted at the gastroesophageal junction. Repeat endoscopy revealed a submucosal tear at the gastroesophageal junction. This is the first reported complication of the Halo(®) 90 system when used for gastric antral vascular ectasia.

Chronic anemia due to watermelon stomach

Antral gastric vascular ectasia is a rare cause of chronic anemia. When encountered, the diagnosis is usually delayed. Endoscopic findings are well established, although radiologic findings are not. Patients respond well to surgery. Our case was of a 62-year-old female with chronic anemia who required multiple blood transfusions and iron replacement therapy, without significant response. Computed tomography revealed a focal thickening of the gastric antrum. Endoscopy showed vascular ectasia between the antrum and corpus. The patient underwent gastrectomy. We reviewed the literature on gastric angiodysplasia and have presented our unique tomography findings in this first report on a novel association between ectopic pancreas and gastric angiodysplasia.

Cardiac Pacemaker and Wireless Capsule Endoscopy Interference: Case Report in a Patient with Gastric Vascular Ectasias

Wireless capsule endoscopy is a new endoscopic tool for the diagnosis and management of small bowel diseases. The main indication at present is the evaluation of GI bleeding of obscure origin, Crohn’s disease, coeliac disease and small bowel tumors. Studies suggest that capsule endoscopy is associated with few adverse events. Whether cardiac pacemaker may interfere with capsule endoscopy is still a controversial issue. We here report a case showing that there is a possibility of interference between the two procedures, cardiac pacemaker affecting the proper functioning of capsule endoscopy and that this is related to the distance between the pacemaker and the recorder.

Efficacy of argon plasma coagulation in gastric vascular ectasia in patients with liver cirrhosis.

To determine the efficacy of Argon Plasma Coagulation (APC) in terms of improvement in hemoglobin level and disappearance of telangiectasia as endoscopic treatment for Gastric Antral Vascular Ectasia (GAVE) and Diffuse Antral Vascular Ectasia (DAVE) syndrome in liver cirrhosis. Quasi experimental study. Department of Gastroenterology and Hepatology of Shaikh Zayed Hospital/ Federal Postgraduate Medical Institute, Lahore, from January, 2006 to July, 2007. Cirrhotic patient with gastric vascular ectasia were enrolled and followed-up for 18 months with repeated sessions of APC. Efficacy of APC was evaluated on the basis of patient's symptoms, transfusion requirements and hemoglobin levels. APC was performed by using ERBE generator set at 60 W and flow rate 2.0 L/min using primarily endfiring probes. Fifty patients were enrolled in the study. Mean age was 55.78+1.24 years with 32 males and 18 females giving a male to female ratio 1.7:1. Forty two patients were in Child's Class C and 8 in Child's Class B. Presenting complaints were malena and anemia. Two hundred and fifty three APC sessions were carried out; mean 5.06+1.5 sessions per patient. Mean follow-up period after the last session was 8.5+3.7 months. Mean increase in the hemoglobin level was 1.35+0.24 g/dl. There was no death of any patient during the study period. Treatment with APC is an effective and safe method to decrease blood loss in patients with GAVE and DAVE.