Treatment Of Gastric Antral Vascular Ectasia Research Articles

Endoscopic band ligation in the treatment of gastric antral vascular ectasia: a systematic review and meta-analysis

Gastric antral vascular ectasia (GAVE) is typically treated by endoscopic thermal therapies. Endoscopic band ligation (EBL) has been reported in the treatment of GAVE with encouraging results. However, EBL is not widely used to this end. We conducted a comprehensive search of several databases (inception to May 2021) to identify studies reporting on the use of EBL in the treatment of GAVE. A random-effects model was used to calculate the pooled rates; I2 values and 95% prediction intervals were calculated to assess the heterogeneity. Ten studies (194 patients) were included in the final analysis. The pooled rate of treatment responders with EBL in GAVE was 81% (95% confidence interval [CI], 62.2-91.7), and GAVE recurrence was 15.4% (95% CI, 4.5-41.3). The pooled mean number of treatment sessions required was 2.4 (95% CI, 2.2-2.7), and the number of bands used to achieve eradication per patient was 15.1 (95% CI, 10.7-19.4). The pooled mean difference of pre- to post-treatment hemoglobin was 1.5 (95% CI, .9-2.2; P= .001), pre- to post-treatment units of packed red blood cells transfused was 1.1 (95% CI, .4-1.9; P= .002), and pre- to post-treatment hospital length of stay was .5 days (95% CI, .1-.9; P= .01). The pooled rate of overall adverse events was 15.9% (95% CI, 10.4-23.7). EBL demonstrated excellent clinical outcomes in the treatment of GAVE with minimal adverse events. Multicenter randomized controlled trials comparing EBL and other modalities as initial therapy are warranted.

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.

Endoscopic band ligation versus argon plasma coagulation in management of bleeding from gastric antral vascular ectasia in patients with portal hypertension

Background Gastric antral vascular ectasia (GAVE) may cause recurrent hemorrhage, and thus, chronic anemia, in patients with portal hypertension. Treatment with argon plasma coagulation (APC) is an effective and safe method in adults but requires multiple sessions of endoscopic therapy. Endoscopic band ligation (EBL) was found to be a good alternative for APC as a treatment for GAVE, especially in refractory cases. The aim of this prospective study was to evaluate the safety and efficacy of EBL, as compared with APC, in treating nonvariceal upper GI bleeding GAVE in patients with portal hypertension. Patients and methods A total of 40 patients with bleeding from GAVE were prospectively randomized to endoscopic treatment with either EBL or APC, every 4 weeks, until complete obliteration was accomplished. Hemoglobin level was obtained before and after treatment; then they were followed up endoscopically after 6 months, with documentation of the recurrence of the lesion, if that occurred. Results We found that EBL significantly decreased the number of sessions required for complete obliteration of the lesions (1.85 ± 0.81 sessions compared with 4.15 ± 1.22 sessions in the APC group; P Conclusion We concluded that GAVE could be safely and successfully managed by EBL or APC. Our study revealed that EBL is more effective, more time saving, and is comparable in safety to APC, in treating nonvariceal upper GI bleeding GAVE in patients with portal hypertension.

Comparison Between Argon Plasma Coagulation And Endoscopic Band Ligation InTreatment Of Gastric Antral Vascular Ectasia In Egyptian Cirrhotic Patients

Background and study aim: The Gastric antral vascular ectasia (GAVE) is one of the causes of upper gastrointestinal bleeding and accounts nearly four percent of all non-variceal upper gastrointestinal hemorrhage. Although Argon Plasma Coagulation is the standard treatment of GAVE, EBL may be used in the treatment of GAVE. This study was done to evaluate the therapeutic effect of APC in comparison to EBL for the treatment of bleeding GAVE in cirrhotic patients. Patients and Methods: Our study was conducted on 36 adult cirrhotic patients with bleeding from GAVE. Patients were divided into 2 groups: 18 patients in each group. Group I was subjected to APC and group II was subjected to EBL. All patients were followed endoscopically after the first endoscopic intervention for 6 months as well as their hemoglobin level had been evaluated monthly during that period. Results: There was a statistically non-significant difference between both treatment groups as regards cessation of bleeding, increase in hemoglobin levels, reduction of transfusion requirements, decreasing of hospital admissions or decreasing of endoscopic recurrence of GAVE during the follow-up period (6 months), but EBL group has a better result than APC group. The application of the EBL technique has significantly increased in the band related complications as hypertrophied polyps and post band ulcerations, which are decreased in the following sessions, in comparison to the APC technique, which had no complications-related. Conclusion: EBL and APC are effective methods in the treatment of bleeding GAVE in cirrhotic patients.

Gastric antral vascular ectasia should not be overlooked in erythropoietin resistance: a series of case reports

Gastric antral vascular ectasia (GAVE) is currently recognized as an important cause of upper gastrointestinal (GI) haemorrhage, being responsible for about 4% of non-variceal upper GI haemorrhages and typically presents in middle-aged females. GAVE, also called "watermelon stomach", is diagnosed through esophagogastroduodenoscopy and is characterized by the presence of visible columns of red tortuous enlarged vessels along the longitudinal folds of the antrum. The pathogenesis is still obscure and many hypotheses have been proposed such as mechanical stress, humoral and autoimmune factors. In the last two decades, numerous therapeutic strategies have been proposed, including surgical, endoscopic, and medical choices, yet successful treatment of GAVE continues to be a challenge. Currently, given the rapid response, safety, and efficacy, endoscopic ablative modalities have largely usurped medical treatments as first-line therapy, particularly using argon plasma coagulation. The actual GAVE prevalence in patients with end-stage renal disease (ESRD) is not clear, yet in difficult cases it should be considered as a cause of erythropoietin resistance. We report four clinical cases of GAVE syndrome patients diagnosed with stage 4 to 5 chronic kidney disease. All patients presented with anaemia and GI haemorrhage, the origin of which turned out to be GAVE syndrome. GAVE syndrome is a serious condition in ESRD patients, especially in those presenting with treatment-refractory anaemia. Realization of its aetiology and characteristics is essential to suspect, diagnose, and treat gastric ectasia. Only proper diagnosis and well-timed disease treatment can significantly improve a patient's medical condition and future prognosis.

Venous ectasia of gastric antrum

Gastric antral vascular ectasia (GAVE) is an uncommon but often severe cause of upper gastrointestinal bleeding. GAVE may be asymptomatic or accompanied by clinical anemia or overt gastrointestinal bleeding. The diagnosis is mainly based on pathognomonic endoscopic pattern, defined as «watermelon stomach», located in antrum. Autoimmune disorders aye co-existing in about 60% of patients with GAVE, chirrosis in about 30%, and cardiac or renal failure in 10%.The "golden standarden" treatment of GAVE is endoscopic argon plasma coagulation (APC). There is poor information about diagnostics and treatment of GAVE in the domestic literature. The analysis of the presented materials shows that correct diagnostics takes much time and the choice of the optimum optimal treatment strategy encounters difficulty. Our experience with diagnostics and therapy of GAVE is based on the treatment of 4 patients. The diagnosis of GAVE was established within the period from 5 months to 1.5 years after onset of the disease. In two cases, GAVE was asymptomatic. Two patients with severe anemia completed endoscopic treatment; in one case, APC was supplemented by laser coagulation and bipolar coagulation. The implementation of laser coagulation caused some technical difficulties. Treatment of both patients was successful. Endoscopy pivotal for diagnosis of GAVE is the main method of its treatment. Due to the large number of diagnostic errors and the importance of correct diagnosis of GAVE, it is necessary to pay attention to this issue in training programs for endoscopists.

Successful treatment of refractory gastric antral vascular ectasia using transcatheter arterial embolization.

In January 2008, a 67-year-old woman was admitted to our hospital because of hepatitis C virus-related cirrhosis and hepatocellular carcinoma (HCC). In February 2010, she had tarry stools and anemia resulting from gastric antral vascular ectasia (GAVE). Argon plasma coagulation (APC) treatment for GAVE was performed at that time. She revisited our hospital in July 2010 because of tarry stools and anemia caused by GAVE recurrence, which required 5 APC sessions and blood transfusion to control the bleeding. In October 2010, she arrived at our hospital by ambulance because of hemorrhagic shock resulting from GAVE recurrence. Despite performing 5 APC sessions and multiple blood transfusions, the tarry stools and anemia persisted during the hospitalization period. In December 2010 and January 2011, second-stage selective transcatheter arterial embolization (TAE) of the right gastric and right gastroepiploic arteries using microcoils was performed for the treatment of the refractory GAVE. Upper gastrointestinal endoscopy performed after TAE revealed the disappearance of mucosal diffuse spotty redness. In addition, no complications such as gastric ulcer and necrosis were observed. Selective TAE, effectively resolved the GAVE and anemia, and no recurrence has been observed during the last 24months. Therefore, TAE may be a safe and radical treatment for refractory GAVE.

Endoscopic band ligation versus argon plasma coagulation for gastric antral vascular ectasia associated with liver diseases

The aim of the present study was to evaluate the clinicopathological features and the efficacy of endoscopic treatments in treating gastric antral vascular ectasia (GAVE) in association with liver diseases. Thirty-four patients with the characteristic endoscopic findings of GAVE were enrolled. Endoscopic treatments were carried out for all 34 patients, including argon plasma coagulation (APC) in 22 patients and endoscopic band ligation (EBL) in 12 patients. All 34 patients had iron-deficiency anemia and 21 patients also had a history of tarry stools. The underlying pathologies of chronic liver diseases were liver cirrhosis in 26 patients, liver cirrhosis associated with hepatocellular carcinoma in six, and idiopathic portal hypertension in two. The liver function was classified by Child-Pugh classification: class A (n=6), class B (n=21), and class C (n=7). Antral motility was frequent and intense in all 34 GAVE patients. In the 22 patients who received APC, endoscopies revealed the recurrence of GAVE in 15 patients requiring further treatment by APC (recurrence rate, 68.2%). Seven patients died during the follow-up period, including two cases with bleeding-related deaths. In the 12 patients who received EBL, endoscopies revealed the recurrence of GAVE in one patient requiring further treatment by EBL (recurrence rate, 8.3%). Two patients died during the follow-up period, neither were bleeding-related deaths. The results suggest that GAVE is related to severe liver damage and portal hypertension. APC has a high recurrence rate of GAVE in the medium term after treatment. EBL may be useful as a treatment for GAVE.

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.

Argon Photocoagulation in the Treatment of Gastric Antral Vascular Ectasia and Radiation Proctitis

Gastric antral vascular ectasia (GAVE) and radiation proctitis are two vascular disorders of the gastrointestinal tract that typically present with recurrent gastrointestinal bleeding. Although the pathogenesis of either condition is not known, they are unlikely to be similar. GAVE appears to be related to autoimmune disorders or cirrhosis, while radiation proctitis is the result of pelvic irradiation, most commonly used for the treatment of pelvic malignancies. Medical therapies for both conditions are not typically effective, and surgical therapies are usually not required because endoscopic treatment, aimed at coagulation of the underlying vascular lesions, has evolved as the most effective therapy. There is limited evidence in the literature for the use of medical and surgical therapies, with most of the evidence coming from case reports involving small numbers of patients. In the present article, we review the evidence for the use of argon plasma photocoagulation (APC, the most commonly used endoscopic modality) in the treatment of GAVE and radiation proctitis.

Treatment of gastric antral vascular ectasia (watermelon stomach) with endoscopic band ligation

Gastric antral vascular ectasia (GAVE) is characterized by mucosal and submucosal vascular ectasia causing recurrent GI hemorrhage. Treatment of GAVE with endoscopic thermal therapy (ETT) requires multiple sessions for destruction of vascular ectasia and control of bleeding. Endoscopic band ligation (EBL) has become the standard treatment of varices because it effectively obliterates the submucosal plexus of esophageal varices with an acceptably low rate of complications. Additionally, EBL has been used for control of bleeding from other GI vascular lesions. In patients with GAVE and recurrent GI hemorrhage, EBL may offer an alternative to ETT for treatment of large areas of diseased mucosa and submucosa. Our purpose was to compare EBL (n = 9) with ETT (n = 13) for the treatment of bleeding from GAVE. Observational comparative study. Patients with gastric antral vascular ectasia with occult or overt bleeding. Mayo Clinic Arizona, a multispecialty academic medical center. EBL or ETT with argon plasma coagulation or electrocautery. Number of treatments to cessation of bleeding and posttreatment hemoglobin, hospitalization, and transfusion requirement. There were no significant differences in the demographics, clinical presentation, associated portal hypertension, or mean hemoglobin values or the mean number of transfusions or hospitalizations between the 2 groups before treatment. Four patients in the EBL group had failed prior ETT. Compared with ETT, in exploratory statistical testing EBL had a significantly higher rate of bleeding cessation (67% vs 23%, P = .04), fewer treatment sessions required for cessation of bleeding (1.9 vs 4.7, P = .05), a greater increase in hemoglobin values (2.8 g/dL vs 0.9 g/dL, P = .05), a greater decrease in transfusion requirements (-12.7 vs -5.2, P = .02), and a greater decrease in hospital admissions (-2.6 vs -0.5, P = .02) during the follow-up period. Analysis of covariance showed significantly superior efficacy of EBL for cessation of bleeding, postprocedure transfusion, and hospitalization. One patient in the EBL group had postprocedure emesis and 1 in the ETT group had immediate post procedure bleeding. All patients in the EBL group had complete mucosal healing with minimal residual GAVE at follow-up endoscopy failed post-EBL. Our initial experience suggests that EBL is superior to ETT for the management of GAVE. EBL required fewer treatment sessions for control of bleeding, had higher rates for cessation of bleeding, had a reduction in hospitalizations and transfusion requirements, and allowed for a significant increase in hemoglobin values.

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.

Treatment of chronic bleeding from gastric antral vascular ectasia (GAVE) with estrogen-progesterone in a cirrhotic patient

A 71-year-old man with type C liver cirrhosis was diagnosed as gastric antral vascular ectasia (GAVE) base on pathognostic endoscopic findings of diffuse erythematous spots in the antrum. He showed severe anemia that needed regular blood transfusion. He was administered estrogen-progesterone (E-P) because endoscopic heater probe therapy was unsuccessful. Gastric bleeding stopped after the induction of E-P therapy. Severe anemia, recurring after the discontinuation because of moving, again ameliorated after the re-induction of E-P therapy, in spite of the spread of GAVE to lower gastric body. This case suggests that E-P therapy is effective in the treatment of GAVE.

Treatment of chronic bleeding from gastric antral vascular ectasia (GAVE) with estrogen-progesterone in cirrhotic patients: an open pilot study.

Gastric antral vascular ectasia (GAVE) is a rare cause of chronic bleeding in cirrhotic patients. Treatment of GAVE with surgical or nonsurgical portal decompression, beta-blockers, or endoscopic therapy provides disappointing results. In the present study, we evaluated the efficacy of estrogen-progesterone therapy, which has been reported to control chronic bleeding in gastrointestinal vascular malformations, such as Osler-Weber Rendu disease or angiodysplasia, in GAVE-related chronic bleeding. Six cirrhotic patients who bled chronically from GAVE were included. Three had alcoholic cirrhosis, two cryptogenic cirrhosis, and one primary biliary cirrhosis. Grade 1 esophageal varices were noted in four patients. Bleeding could not be controlled by beta-blockers, and endoscopic therapy was not considered given the extension of the antral vascular lesions. Before the start of therapy, transfusion requirements averaged 3.5 units/month over a 1.5-11 month period of observation. Patients were then treated with a combination of ethynil estradiol 30 microg and noretisterone 1.5 mg daily. During follow-up (range 3-12 months), bleeding did not recur in four patients; in one patient, treatment with estrogen progesterone decreased the need for transfusions from 4 units/month to 1.4 unit/month; this patient stopped the treatment inadvertently after 6 months and severe anemia recurred with a need for 4 units of blood in the following month; reintroduction of the treatment resulted in an increase of hemoglobin levels without the need for blood transfusions during the following 4 months. In the last patient, a 5-month treatment did not improve chronic bleeding. The present study suggests that estrogen-progesterone therapy is useful in the treatment of chronic bleeding related to GAVE; however, these findings require confirmation by a controlled trial.

Treatment of chronic bleeding from gastric antral vascular ectasia (GAVE) with estrogen-progesterone in cirrhotic patients: an open pilot study

OBJECTIVE: Gastric antral vascular ectasia (GAVE) is a rare cause of chronic bleeding in cirrhotic patients. Treatment of GAVE with surgical or nonsurgical portal decompression, β-blockers, or endoscopic therapy provides disappointing results. In the present study, we evaluated the efficacy of estrogen-progesterone therapy, which has been reported to control chronic bleeding in gastrointestinal vascular malformations, such as Osler-Weber Rendu disease or angiodysplasia, in GAVE-related chronic bleeding. METHODS: Six cirrhotic patients who bled chronically from GAVE were included. Three had alcoholic cirrhosis, two cryptogenic cirrhosis, and one primary biliary cirrhosis. Grade 1 esophageal varices were noted in four patients. Bleeding could not be controlled by β-blockers, and endoscopic therapy was not considered given the extension of the antral vascular lesions. RESULTS: Before the start of therapy, transfusion requirements averaged 3.5 units/month over a 1.5–11 month period of observation. Patients were then treated with a combination of ethynil estradiol 30 μg and noretisterone 1.5 mg daily. During follow-up (range 3–12 months), bleeding did not recur in four patients; in one patient, treatment with estrogen progesterone decreased the need for transfusions from 4 units/month to 1.4 unit/month; this patient stopped the treatment inadvertently after 6 months and severe anemia recurred with a need for 4 units of blood in the following month; reintroduction of the treatment resulted in an increase of hemoglobin levels without the need for blood transfusions during the following 4 months. In the last patient, a 5-month treatment did not improve chronic bleeding. CONCLUSIONS: The present study suggests that estrogen-progesterone therapy is useful in the treatment of chronic bleeding related to GAVE; however, these findings require confirmation by a controlled trial.