GE Port J Gastroenterol. 2016;23(5):249---253

www.elsevier.pt/ge

CLINICAL CASE

Treating Gastric Antral Vascular Ectasia --- When ArgonTherapy Is Not Enough

Francisca Dias de Castroa,∗, Pedro Boal Carvalhoa, Tiago Cúrdia Goncalvesa,Joana Magalhãesa, Maria João Moreiraa, Carla Marinhoa, José Cottera,b,c

a Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugalb Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugalc ICVS/3B’s, PT Government Associate Laboratory, Guimarães, Portugal

Received 4 December 2015; accepted 3 January 2016Available online 23 February 2016

KEYWORDSEndoscopyGastrointestinal;Gastric AntralVascular Ectasia;Argon PlasmaCoagulation;Ligation

Abstract Gastric antral vascular ectasia (GAVE) is a capillary-type vascular malformation of thegastric antrum and an infrequent cause of chronic gastrointestinal blood loss and iron deficiencyanemia.

The authors describe a case report of GAVE in a female cirrhotic patient presenting withsevere symptomatic iron deficiency anemia. After failure of argon plasma coagulation (APC),the patient was treated with endoscopic band ligation (EBL) with resolution of anemia, withoutnew episodes of rebleeding and no need for further hospitalizations or transfusion requirements.

Even though APC is the current treatment of choice for GAVE recurrence-free survival at oneyear is achieved in less than 50% of the patients and failed therapy has been described in up to14% of the patients. EBL has been reported to be a relatively easy technique for GAVE therapyand has been shown to be safe and effective with lower complication rates in comparison withAPC. This technique may in the future be used as the initial endoscopic treatment to eradicateGAVE.© 2016 Sociedade Portuguesa de Gastrenterologia. Published by Elsevier Espana, S.L.U. This isan open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

PALAVRAS-CHAVEEndoscopia

Tratamento da Ectasia Vascular do Antro Gástrico --- Quando a Terapêutica com ÁrgonÉ Insuficiente

r do antro gástrico (GAVE) é uma malformacão vascular e uma causa défice de ferro. Os autores descrevem um caso de doente do sexo

de cirrose hepática alcoólica com diagnóstico de GAVE após estudo

Gastrointestinal;Ectasia Vascular doAntro Gástrico;

Resumo A ectasia vasculainfrequente de anemia porfeminino com antecedentes

∗ Corresponding author.E-mail address: franciscacastro@chaa.min-saude.pt (F. Dias de Castro).

http://dx.doi.org/10.1016/j.jpge.2016.01.0022341-4545/© 2016 Sociedade Portuguesa de Gastrenterologia. Published by Elsevier Espana, S.L.U. This is an open access article under theCC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

250 Dias de Castro F et al.

Coagulacão Àrgonplasma;Laqueacão

etiológico de anemia ferropénica sintomática. Após falência do tratamento endoscópico comárgon plasma (APC), a doente foi submetida a laqueacão elástica da GAVE com resolucão daanemia, sem novos episódios de hemorragia e sem necessidade de re-internamentos ou suportetransfusional.

Apesar do APC ser o tratamento de primeira linha para a GAVE a taxa de doentes sem recor-rência em um ano é alcancada em menos de 50% dos doentes, para além de falências primáriasao tratamento rondarem os 14%. A laqueacão elástica tem sido descrita como uma técnica defácil aplicacão no tratamento da GAVE e tem-se revelado segura, eficaz e com baixa taxa decomplicacões em comparacão com o APC. Esta técnica pode, no futuro, ser utilizada comotratamento endoscópico inicial para a erradicacão da GAVE.© 2016 Sociedade Portuguesa de Gastrenterologia. Publicado por Elsevier Espana, S.L.U. Estee um artigo Open Access sob uma licenca CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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. Introduction

astric antral vascular ectasia (GAVE) is a capillary-typeascular malformation of the gastric antrum1 and an infre-uent cause of chronic gastrointestinal blood loss and ironeficiency anemia. GAVE is responsible for up to 4% of non-ariceal upper gastrointestinal (GI) bleeding and 6% of upperI bleeding in cirrhotic patients.2,3

Most cases are idiopathic, but it is frequently associ-ted with other clinical conditions, such as cirrhosis andutoimmune diseases,4 with a prevalence reported in cir-hotic patients of 12%3 and reaching 30% in patients withiver failure.5

At oesophagogastroduodenoscopy (OGD), GAVE mayppear as multiple longitudinal streaks that converge athe pyloric orifice, with a ‘‘watermelon’’ pattern (stripeype), or as multiple erythematous spots (diffuse or granularype).6 This last form occurring more frequently in patientsith cirrhosis.6

The current treatment of choice for GAVE is endoscopicntervention with argon plasma coagulation (APC).7 Howeverecurrence-free survival at one year is achieved in less than0% of the patients8 and in addition rates of failed therapyf up to 14% have been reported.3 Equally important to refers the complication rate which is high (20---30%).3

The authors describe a case report of GAVE in a femaleirrhotic patient presenting with severe symptomatic ironeficiency anemia. After failure of APC, the patient wasreated with endoscopic band ligation (EBL) with resolutionf anemia, without new episodes of rebleeding and no needor further hospitalizations or transfusion requirements.

. Case presentation

69-years-old female presented with a three-week historyf fatigue. She denied hematemesis and abdominal pain, andhere was no change in appetite, weight, bowel pattern, ortool color. She had a medical history of alcoholic cirrho-

is (Child Pugh A, MELD 7 points) and was on furosemide,ad no known allergies and no family history of gastroin-estinal pathology. She denied consumption of nonsteroidalnti-inflammatory and smoking habits.

artp

Figure 1 Gastric antral vascular ectasia.

Physical examination revealed paleness of the skin anducosae and sinus tachycardia with normal blood pressure.

ectal examination did not reveal blood in stools.Laboratory data evidenced severe anemia with

emoglobin level of 4.0 g/dL, low platelet count, nor-al coagulation parameters and inflammatory markersere normal. Iron study revealed a serum iron level of4 �g/dL (reference range 50---170 �g/dL) with a totalron binding capacity of 398 �g/dL (reference range50---450 �g/dL) and ferritin of 2.8 ng/mL (reference range---252 ng/mL). Transfusion of red blood cells was initiatedith hemoglobin level increasing to 7.7 g/dL.

An OGD was performed and revealed multiple erythema-ous spots in the antrum compatible with GAVE, diffuse typeFig. 1), and mild portal hypertensive gastropathy, with-ut active bleeding. There was no evidence of esophagealr gastric varices. GAVE was treated with APC withoutomplications (Fig. 2). A colonoscopy with ileoscopy waslso performed, but it was negative for blood or hemor-

hagic lesions. Her hemoglobin levels remained stable andhe patient was discharged and started on propranolol (forortal hypertensive gastropathy), with a target of 55 beats

Treating Gastric Antral Vascular Ectasia --- When Argon Therapy Is Not Enough 251

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Figure 2 Gastric antral vascular ectasia --- after APC treat-ment.

per minute, 40 mg of pantoprazole every 24 h and performediron intravenous supplementation in ambulatory.

During the following 4 months, the patient had 3 newepisodes of severe symptomatic anemia requiring trans-fusion. During these episodes she underwent OGD thatrevealed persistence of GAVE and APC treatments were per-formed.

Nevertheless the patient presented with a new episodeof symptomatic anemia, and an hemoglobin level of 3.7 g/dLwas observed. After transfusion of red blood cells an OGDwas performed. At that time, since GAVE persisted despitetreatment sessions using APC, and taking into considerationthe severity and short recurrence intervals of symptomaticanemia, a decision was made to perform EBL (multi-band lig-ator, Ezy Shoot, G-Flex®). Six bands were applied, startingfrom lesions adjacent to the pylorus, then continued proxi-mally in the antrum until most of the GAVE affected areaswere treated (Fig. 3). No complications of the procedurewere reported, and the patient was discharged after 24 h,maintaining propranolol and pantoprazole. Endoscopic eval-

uation was performed every 4 weeks and another 3 sessionsof EBL were performed with almost complete eradication ofGAVE (Fig. 4). Following the first EBL treatment the patientremained asymptomatic with stable hemoglobin level of

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Figure 3 EBL treatment.

igure 4 Gastric antral vascular ectasia --- after EBL treatment4 sessions).

2 g/dL and no need of red cells blood transfusion or ironupplementation.

. Discussion

AVE is a poorly understood entity, of unknown etiology,nd an increasingly identifiable cause of chronic iron defi-iency anemia. The pharmacological management of GAVEas been met with disappoint results, and the mainstay ofAVE management remains endoscopic therapy.3,9

APC is a modality of non-contact electrocoagulation thatpplies high-frequency energy into tissue to cause ther-al effects, which can be used for hemostasis.10 APC haseen used successfully to treat GAVE with an effective tran-ient response, but primary failure rates of therapy of upo 14% have been reported.3 Some authors11---13 suggest thathis endoscopic modality is insufficient in order to achieveedium and long-term treatment success, as it has been

ssociated with a high recurrence rate (40---100%), with lesshan 50% of the patients achieving a recurrence-free sur-

ival at one year.8 In addition to this limitation, APC resultsn complications, such as sepsis, pyloric stenosis and gastricutlet obstruction syndrome, in 20---33% of the patients.3

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festations of watermelon stomach. Endoscopy. 2003;35:1024---8.

52

EBL has been reported to be a relatively easy techniqueor GAVE therapy, has been shown to be safe and effectiveith lower complication rates in comparison with APC.14,15

recent prospective study showed endoscopic improve-ent with the use of EBL in 91% of the patients, associatedith a significant improvement in the hemoglobin and fer-

itin levels. EBL in GAVE has been associated with transientbdominal pain in a minority of the patients but no majoromplications have been reported in the literature.14

Another new option therapy for GAVE is radiofrequencyblation, which allows larger mucosal surfaces to bereated. A recent study16 suggests that radiofrequency abla-ion is a safe and effective treatment for recurrent bleedingrom GAVE. However this technique requires additionalraining, is more expensive than other options and is notidely available.16 Potential complications are the same as

or APC and includes perforation and bleeding.16

In this case, the patient was initially treated with APCfter being diagnosed with GAVE as the cause of severe ironeficiency anemia, however this strategy was not successful.PC treatment might not be effective in some cases and thisould be explained by the limited depth of thermal injury.10

Even tough portal hypertensive gastropathy was mild androbably not the cause of anemia, because of the severeresentation without active bleeding, the patient startedn propranolol which is the first line treatment to reduceortal pressure.9

EBL is widely employed as an effective treatment forsophageal varices because of its capacity to obliterate sub-ucosal varices. With respect to GAVE, since the histological

hanges are present in the mucosa and submucosal layer,BL may be more effective because of its ability to oblit-rate the submucosal vascular plexus.10 In this patient, theresence of extensive areas of the antrum affected with aigh-density of both mucosal and submucosal vascular mal-ormations is a likely explanation for the primary failuref the APC treatment. Given the fast recurrence of severenemia, often within 4 weeks, the decision to perform EBLielded positive results, with eradication of GAVE with 4essions of EBL with no complications, namely abdominalain.

Even though our case report is in accordance with recentiterature some issues still need to be elucidated in ordero improve the treatment of GAVE with EBL. The optimalnterval between treatment sessions, the potential role ofombined therapy with APC in patients with poor responsend the need of endoscopic surveillance for recurrence afterradication since the etiology of GAVE are still unknown.

Some studies14,15 suggest that the number of sessionsequired for GAVE eradication is inferior when using EBLompared to APC, resulting in inferior health care costsor that group of patients. However, randomized controlledrials are lacking to determine whether EBL is more costffective than APC as the primary endoscopic therapy forAVE.

In summary, GAVE is a rare cause of chronic gastrointesti-al blood loss and iron deficiency anemia, often associatedith chronic diseases such as cirrhosis. We report annusual case of GAVE with severe symptomatic anemia,

ith no response to primary endoscopic therapy with APCespite correct intravenous iron supplementation betweenndoscopic treatments. After initiating GAVE eradication

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Dias de Castro F et al.

ith EBL the patient became asymptomatic. EBL may inhe future be used as the initial endoscopic treatment toradicate GAVE, but larger studies are needed to clarify thisssue.

thical disclosures

rotection of human and animal subjects. The authorseclare that no experiments were performed on humans ornimals for this study.

onfidentiality of data. The authors declare that they haveollowed the protocols of their work center on the publica-ion of patient data.

ight to privacy and informed consent. The authorseclare that no patient data appear in this article.

onflicts of interest

he authors have no conflicts of interest to declare.

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