Refractory Gastric Antral Vascular Ectasia Research Articles

Surgical treatment of gastric antral vascular ectasia. Clinical case

A clinical case of a 67-year-old patient suffering from severe iron deficiency anemia, caused by gastric antral vascular ectasia (GAVE), is described. This type of gastric angiodysplasia is characterized by a distinct endoscopic picture and is a rare cause of gastric bleeding. Endoscopic hemostasis is considered the main method of treatment, however, after argon plasma coagulation (APC), in our case, anemia recurred, and required repeated hospitalization and blood transfusion. Indications for surgical treatment were established, and Billroth I antrumectomy proved to be effective in refractory GAVE.

S3181 The GAVE That Keeps on Giving: A Case of Refractory Gastric Antral Vascular Ectasia

S3181 The GAVE That Keeps on Giving: A Case of Refractory Gastric Antral Vascular Ectasia

Endoskopická a lékařská terapie žaludeční antrální vaskulární ektázie: případová řada a přehled dostupných metod

Gastric antral vascular ectasia (GAVE) is an uncommon dia­gnosis leading to chronic iron deficiency anaemia caused by occult or overt gastrointestinal bleeding. The mainstay of the therapy is based on endoscopic therapy using endoscopic thermal methods – particularly argon plasma coagulation and others – radiofrequency ablation, coagulation or cryotherapy. Endoscopic band ligation presents satisfying results as well. Pharmacotherapy aiming at reduction of the development of new vascular lesions and reduction of blood flow in them could be considered in patients refractory to endoscopic treatment. We present a review of available endoscopic and non-endoscopic methods for GAVE therapy and our experience with the therapy of refractory GAVE using a combination of endoscopic methods and thalidomide on case series. The algorithm for GAVE therapy is proposed.

Endoscopic treatment for gastric antral vascular ectasia.

Gastric antral vascular ectasia (GAVE) is one of the uncommon causes of upper gastrointestinal bleeding. Major treatment of GAVE includes pharmacotherapy, endoscopy, and surgery. The efficacy and safety of pharmacotherapy have not been sufficiently confirmed; and surgery is just considered when conservative treatment is ineffective. By comparison, endoscopy is a common treatment option for GAVE. This paper reviews the currently used endoscopic approaches for GAVE, mainly including argon plasma coagulation (APC), radiofrequency ablation (RFA), and endoscopic band ligation (EBL). It also summarizes their efficacy and procedure-related adverse events. The endoscopic success rate of APC is 40–100%; however, APC needs several treatment sessions, with a high recurrence rate of 10–78.9%. The endoscopic success rates of RFA and EBL are 90–100% and 77.8–100%, respectively; and their recurrence rates are 21.4–33.3% and 8.3–48.1%, respectively. Hyperplastic gastric polyps and sepsis are major adverse events of APC and RFA; and Mallory–Weiss syndrome is occasionally observed after APC. Adverse events of EBL are rare and mild, such as nausea, vomiting, esophageal or abdominal pain, and hyperplastic polyps. APC is often considered as the first-line choice of endoscopic treatment for GAVE. RFA and EBL have been increasingly used as alternatives in patients with refractory GAVE. A high recurrence of GAVE after endoscopic treatment should be fully recognized and cautiously managed by follow-up endoscopy. In future, a head-to-head comparison of different endoscopic approaches for GAVE is warranted.

Radiofrequency Ablation (RFA) for the Treatment of Refractory Gastric Antral Vascular Ectasia: A Systematic Review and Meta-Analysis

Radiofrequency Ablation (RFA) for the Treatment of Refractory Gastric Antral Vascular Ectasia: A Systematic Review and Meta-Analysis

Radiofrequency ablation for gastric antral vascular ectasia and radiation proctitis.

Gastric antral vascular ectasia (GAVE) and chronic radiation proctitis (CRP) are well-known causes of repeated gastrointestinal bleeding and iron deficiency anemia. Argon plasma coagulation (APC) is the most common endoscopic therapy used, but some patients need multiple APC sessions. Radiofrequency ablation (RFA) is recently used in GAVE and CRP treatment with promising results. In this case series, we analyzed data for 15 patients with GAVE and 5 patients with CRP that had multiple prior APC treatment. They were treated with RFA HALO 90 catheter (HALO90 Ablation Catheter System; Covidien, GI Solutions, Sunnyvale, CA) in our tertiary referral center. A total of 20 patients received 32 RFA procedures (8 in the CRP group and 24 in the GAVE group). The median number of the procedures was 2 (range 1-4). The hemoglobin levels in the GAVE group were 83g/L pre-RFA and 98g/L post-RFA and in the CRP group, 86g/L pre-RFA and 103g/L post-RFA. A total of 16/20 patients (80%) were transfusion-free after the completion of RFA treatment. Technical success of the treatment was 95% (19/20 patients). RFA can be safely and successfully used in APC refractory GAVE and CRP patients.

Radiofrequency Ablation for Treatment of Refractory Gastric Antral Vascular Ectasia: A Systematic Review of the Literature.

Background and Study Aims GAVE is an uncommon cause of upper nonvariceal bleeding and often manifests itself as occult bleeding with chronic anemia. To date, the standard of care for GAVE is endoscopic treatment with thermoablative techniques. Despite good technical results, approximately two thirds of patients remain dependent on transfusions after the therapy. One of the emerging and more promising endoscopic treatments for GAVE is radiofrequency ablation (RFA). The aim of this study is to perform a systematic review of literature in order to assess current evidence supporting the effectiveness of this technique for treatment of refractory GAVE. Materials and Methods Through electronic search, we identified 14 records, and after removal of duplicates and irrelevant studies, we selected 10 studies on radiofrequency ablation of GAVE: 4 prospective open-label single-center studies, 1 retrospective multicentric study, and 5 case reports. Results Among all 72 treated patients reported in literature, 74.3% achieved a clinical response, while nonfatal AEs have been reported in 4.2% of cases. Conclusions Despite some qualitative limitations, all literature data support effectiveness of RFA for treatment of refractory GAVE. In the future, large prospective controlled trials with adequate follow-up are needed to better assess the effectiveness and safety of this procedure.

Radiofrequency ablation for treatment of refractory gastric antral vascular ectasia (with video).

Background and study aims: Gastric antral vascular ectasia (GAVE) is a known cause of gastrointestinal bleeding and chronic iron deficiency anemia. Endoscopic therapy with argon plasma coagulation (APC) is widely used for treatment of GAVE, but most patients continue to require repeated blood transfusions and multiple endoscopic procedures (refractory GAVE). We describe our initial experience regarding safety and efficacy of radiofrequency ablation (RFA) therapy in treating patients with refractory GAVE. Patients and methods: We prospectively enrolled seven patients with refractory GAVE who had multiple prior treatments with APC. These patients were treated with RFA (HALO90 ULTRA Ablation Catheter System; Covidien, GI Solutions, Sunnyvale, CA) at Ertan Digestive Disease Center at our tertiary University Hospital. Results: Seven patients underwent a total of 12 RFA procedures for treatment of refractory GAVE. The median number of RFA procedures was 2 (Range, 1 – 3). Average pre- and post-procedural hemoglobin were 9.3 g/dL and 10.16 g/dL, respectively. Five of seven patients (71 %) were transfusion-free after the RFA treatments while two patients continued to require blood transfusions. There were no complications in this series. Conclusion: RFA can be an effective alternative to APC for treatment of GAVE refractory to previous endoscopic therapy. Additional studies are needed to identify which subset of patients will benefit the most with RFA treatment.

Treatment resistant gastric antral vascular ectasia in a patient undergoing haemodialysis.

Gastric antral vascular ectasia (GAVE) is an important cause of upper gastrointestinal bleeding and has a high prevalence in patients with renal insufficiency. We report the first documented case of a 52-year-old patient on haemodialysis with GAVE refractory to repeated endoscopic argon plasma coagulation (APC) therapy and highlight the difficulties in its management. We recognise the need for further studies to investigate the optimal management of this condition and suggest alternative treatment strategies to be considered in patients with APC refractory GAVE, such as endoscopic band ligation and changing dialysis modality.

Refractory gastric antral vascular ectasia treated by a novel through-the-scope ablation catheter

Refractory gastric antral vascular ectasia treated by a novel through-the-scope ablation catheter

Radiofrequency Ablation for Treatment of Refractory Gastric Antral Vascular Ectasia

Purpose: Gastric antral vascular ectasia (GAVE) is a known cause of gastrointestinal bleeding and chronic iron deficiency anemia. Endoscopic therapy with argon plasma coagulation (APC) is widely used for treatment of GAVE, but a majority of patients continue to require repeated blood transfusions and multiple endoscopic procedures (refractory GAVE). We describe our experience with the use of radiofrequency ablation (RFA) therapy in treating patients with refractory GAVE. Methods: Prospective case series of seven patients with refractory GAVE who were treated with RFA (HALO90 ULTRA Ablation Catheter System; Covidien, GI Solutions, Sunnyvale, CA). Results: Seven patients (one male, six females, mean age of 69 years, range 56-82) underwent RFA for treatment of refractory GAVE (12 total procedures). All of the patients had previously undergone endoscopic therapy with APC. 4 (57%) of the seven required multiple RFA treatments. Average pre- and post-procedural hemoglobin were 9.3 (SD 0.78) and 10.16 (SD 1.72; p >0.05), respectively. Two (29%) of the seven patients required post-procedural transfusions. Conclusion: Radiofrequency ablation is an effective alternative to APC for treatment of GAVE refractory to previous endoscopic therapy. Five (71%) of seven patients are transfusion-free after the RFA treatment. Further studies are needed to identify which subset of patients will benefit the most with RFA treatment.Table 1: Patient demographics

Continuing Medical Education Exam: October 2013

Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely online. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Bryant RV, Kuo P, Williamson K, et al. Performance of the Glasgow-Blatchford score in predicting clinical outcomes and intervention in hospitalized patients with upper GI bleeding. Gastrointest Endosc 2013;78:576-83. McGorisk T, Krishnan K, Keefer L, et al. Radiofrequency ablation for refractory gastric antral vascular ectasia (with video). Gastrointest Endosc 2013;78:584-8. Fuccio L, Hassan C, Laterza L, et al. The role of K-ras gene mutation analysis in EUS-guided FNA cytology specimens for the differential diagnosis of pancreatic solid masses: a meta-analysis of prospective studies. Gastrointest Endosc 2013;78:596-608. Hayashi N, Tanaka S, Hewett DG, et al. Endoscopic prediction of deep submucosal invasive carcinoma: validation of the Narrow-Band Imaging International Colorectal Endoscopic (NICE) classification. Gastrointest Endosc 2013;78:625-32. 2. Log in online to complete a single examination with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the examination and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.

Radiofrequency ablation for refractory gastric antral vascular ectasia (with video)

Gastric antral vascular ectasia (GAVE) is a cause of upper GI bleeding and chronic anemia. Although upper endoscopy with argon plasma coagulation (APC) is an accepted therapy for GAVE, many patients continue to bleed and remain transfusion dependent after therapy. Radiofrequency ablation (RFA) may provide an alternative therapeutic option for GAVE. To determine the efficacy and safety of RFA for patients with GAVE who remain transfusion dependent after APC treatment. Open-label prospective cohort study of patients with GAVE refractory to APC. Academic tertiary referral center. GAVE patients with previous failed APC therapy, chronic anemia, and transfusion dependence. Endoscopic RFA to the gastric antrum using the HALO(90) ULTRA ablation catheter until transfusion independence is achieved or a maximum of 4 sessions are performed. Transfusion requirements before and after RFA. Secondary outcomes are hemoglobin before and 6 months after RFA completion, number of RFA sessions, and complications. Twenty-one patients underwent at least 1 RFA session with ablation of GAVE lesions. At 6 months after completion of the course of RFA therapy, 18 of 21 patients (86%) were transfusion independent. Mean hemoglobin increased from 7.8 to 10.2 in responders (n = 18). Two adverse events occurred (minor acute bleeding and superficial ulceration); both resolved without intervention. Single-center, single-operator, and nonrandomized design. RFA is safe and effective for treating patients with refractory GAVE after attempted APC.

Endoscopic band ligation for refractory gastric antral vascular ectasia associated with liver cirrhosis.

An 84-year-old woman with unknown liver cirrhosis was admitted to our hospital in October 2008 with anemia due to recurrent gastric antral vascular ectasia (GAVE). At 78years of age, argon plasma coagulation (APC) was performed for GAVE, and between 79 and 83years of age, APC was carried out five times for recurrent episodes of GAVE presenting as anemia. Upon hospitalization, she was found to have anemic conjunctivae and the laboratory findings were red blood cells 245×10(4)/mm(3) and hemoglobin 7.7g/dL. During this period, endoscopic band ligation (EBL) was performed for the recurrent refractory GAVE. EBL was first applied to the most distal antrum, and subsequent EBLs were performed more proximally. Two weeks after initial EBL treatment, endoscopy revealed both ulcers and shrinking of GAVE in the stomach. Fourteen months later, no further recurrence of GAVE was observed by endoscopy. This patient had no episodes of bleeding during the 20month period since she was treated with EBL, and has a hemoglobin value of 10.1g/dL. The histologic changes that occur with GAVE exist in the mucosal and submucosal region of the stomach; therefore, EBL may be effective for refractory GAVE because of obliterating submucosal vascular plexus.

Laparoscopic Surgical Treatment for Refractory Gastric Antral Vascular Ectasia

Gastric antral vascular ectasia (GAVE) is an angiodysplastic disorder of unclear etiology and rare cause of upper gastrointestinal bleeding. Endoscopic findings of hyperemic antral folds with dilated, tortuous vessels extending radially from the pylorus are diagnostic. Ectatic submucosal capillaries, microvascular fibrin thrombosis, and fibromuscular hyperplasia in the lamina propria are distinctive histologic features. Diverse treatment options are available, ranging from conservative medical or endoscopic therapy to surgical resection of affected gastric region. Surgery is the only known curative treatment and is traditionally pursued after failure of conservative therapy, as high postoperative mortality has been reported. A case of refractory GAVE in a 71-year-old female patient after 5 years of conservative management, is presented. The patient underwent successful laparoscopic distal gastrectomy and gastrojejunostomy with resolution of symptomatic anemia and melena. Clinical findings, diagnosis, etiology, and treatment of GAVE are reviewed here, with discussion of safety and efficacy of laparoscopic gastric resection for its treatment.

Long-Term Follow-Up of Gastric Antral Vascular Ectasia Treated by Argon Plasma Coagulation

Long-Term Follow-Up of Gastric Antral Vascular Ectasia Treated by Argon Plasma Coagulation Shinichi Nakamura, Atsushi Mitsunaga, Itaru Oi, Keiko Shiratori Aims: Melena and anemia due to diapedesis are sometimes observed in patients with gastric antral vascular ectasia (GAVE). Argon plasma coagulation (APC) is a non-contact electrocoagulation method used to achieve hemostasis. It produces rapid, extensive and shallow coagulation and is effective in arresting superficial bleeding. Here we report the long-term results of hemostatic treatment for GAVE using APC. Patients and Methods: The study subjects were 18 patients with GAVE (7 men and 11 women, mean age: 65.0 years) who showed signs of gastrointestinal hemorrhage (melena, low Hb [by O2.0 g/dl], or endoscopy-confirmed bleeding) and were treated with APC between December 1998 and October 2004. Based on endoscopic findings, GAVE was classified as the diffuse type in 15 cases and the watermelon type in 3 cases. At initial diagnosis of GAVE, 13 patients had liver cirrhosis, 9 had renal failure and 2 had valvular heart disease. The median Hb was 7.3 g/dl. APC was performed with a high-frequency generator (ICC200), an automatically regulated argon source (APC300), and flexible APC probes. APC was performed using an argon gas at a flow rate of 1.5-2 1/min and a high-frequency arc output of 50-60 w. Clinical outcome was assessed; if the above-mentioned signs were observed during follow-up, the case was defined as recurrence of GAVE. Cumulative recurrence-free rates were calculated using the Kaplan-Meier method. Results: APC was performed 3.2 G 0.9 times/patient, and resulted in the control of bleeding and resolution of lesions. Recurrence was observed in 12 patients during a 21-month monitoring period (median) after 4.5 G 1.9 sessions of APC. The cumulative recurrence-free rate at 24 months after treatment was 27.7%. There were 5 deaths and 4 refractory patients who showed repeated recurrence over six months. GAVE in these refractory patients was of the watermelon type, and the majority of these patients also suffered from renal failure. No APC-related complications were noted. Conclusion: APC appears to be effective for temporary control of diapedesis and anemia due to GAVE, but is not always effective over the long term. Refractory patients had the watermelon type of GAVE, and most of them also had renal failure. Refractory GAVE appears to be partly related to increased gastric movement. Bleeding due to GAVE should be treated with APC, in addition to other modalities, such as drugs and conservative treatment. Treatment of underlying disease is also important.