1
|
Girão de Caires F, Nunes M, Damiao F, Dionísio I, Gomes da Costa A. Anemia Secondary to Gastric Antral Vascular Ectasia Successfully Treated With Antral Gastrectomy. Cureus 2024; 16:e69663. [PMID: 39429396 PMCID: PMC11488673 DOI: 10.7759/cureus.69663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2024] [Indexed: 10/22/2024] Open
Abstract
Gastric antral vascular ectasia (GAVE) is a rare but significant cause of chronic gastrointestinal bleeding and anemia, particularly in elderly patients. We report the case of a 75-year-old female who presented with severe anemia secondary to GAVE. Despite multiple endoscopic interventions with argon plasma coagulation (APC) treatments and endoscopic band ligation (EBL), the patient's condition persisted, necessitating an antral gastrectomy with intraoperative endoscopy to delineate the proximal resection margin. Postoperative outcomes were favorable, with no recurrence of anemia or gastrointestinal bleeding observed during follow-up.
Collapse
Affiliation(s)
| | - Mafalda Nunes
- General Surgery, Unidade Local de Saúde do Oeste, Caldas da Rainha, PRT
| | - Filipe Damiao
- Gastroenterology, Unidade Local de Saúde do Oeste, Caldas da Rainha, PRT
| | - Isabel Dionísio
- General Surgery, Unidade Local de Saúde do Oeste, Caldas da Rainha, PRT
| | | |
Collapse
|
2
|
Khalifa A, Rockey DC. Role of Endoscopy in the Diagnosis, Grading, and Treatment of Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia. Gastrointest Endosc Clin N Am 2024; 34:263-274. [PMID: 38395483 DOI: 10.1016/j.giec.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are 2 distinct gastric vascular abnormalities that may present with acute or chronic blood loss. PHG requires the presence of portal hypertension and is typically associated with chronic liver disease, whereas there is controversy about the association of GAVE with chronic liver disease and/or portal hypertension. Distinguishing between GAVE and PHG is crucial because their treatment strategies differ. This review highlights characteristic endoscopic appearances and the clinical features of PHG and GAVE, which, in turn, aid in their appropriate management.
Collapse
Affiliation(s)
- Ali Khalifa
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA.
| |
Collapse
|
3
|
Fortuna L, Bottari A, Bisogni D, Coratti F, Giudici F, Orlandini B, Dragoni G, Cianchi F, Staderini F. Gastric Antral Vascular Ectasia (GAVE) a case report, review of the literature and update of techniques. Int J Surg Case Rep 2022; 98:107474. [PMID: 35963152 PMCID: PMC9386635 DOI: 10.1016/j.ijscr.2022.107474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 07/30/2022] [Accepted: 07/30/2022] [Indexed: 01/10/2023] Open
Abstract
Introduction and importance Gastric Antral Vascular Ectasia is a rare disorder that causes up to 4 % of severe acute gastrointestinal bleeding. It affects elderly females with iron deficiency anemia due to chronic blood loss as a common presenting sign. Case presentation We report the case of a 70-year-old man admitted to the Urgency Department for severe asthenia associated with abdominal pain and severe anemia. An urgent upper endoscopic examination showed antral hyperemic streaks and vascular ectasias extending from the pyloric ring to the gastric body as well as signs of recent bleeding. Histological results demonstrated the pathognomonic features of GAVE. Clinical discussion The first line treatment is considered argon plasma coagulation (APC), given its wider availability, safety, efficacy and cost-effectiveness. In current literature, other therapies and different types of endoscopic treatments have been proposed, such as EBL, RFA and Yag: laser. To date, there is no specific recommendation that privileges one method over another in the treatment of GAVE, although APC has proven effective and even better in terms of complications and costs than the other techniques. Conclusion In our experience, endoscopic coagulation with APC probes is a relatively easy-to-use technique with low cost, minimal invasiveness and provides immediate results. On the other hand, a standardized algorithm is also required concerning to the different subtypes to give the best treatment in every case.
Collapse
|
4
|
Demetiou G, Augoustaki A, Kalaitzakis E. Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review. World J Gastrointest Endosc 2022. [DOI: 10.4253/wjge.v14.i3.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
5
|
Demetriou G, Augoustaki A, Kalaitzakis E. Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review. World J Gastrointest Endosc 2022; 14:163-175. [PMID: 35432740 PMCID: PMC8984531 DOI: 10.4253/wjge.v14.i3.163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/08/2021] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute non-variceal bleeding accounts for approximately 20% of all-cause bleeding episodes in patients with liver cirrhosis. It is associated with high morbidity and mortality therefore prompt diagnosis and endoscopic management are crucial.
AIM To evaluate available data on the efficacy of endoscopic treatment modalities used to control acute non-variceal gastrointestinal bleeding (GIB) in cirrhotic patients as well as to assess treatment outcomes.
METHODS Employing PRISMA methodology, the MEDLINE was searched through PubMed using appropriate MeSH terms. Data are reported in a summative manner and separately for each major non-variceal cause of bleeding.
RESULTS Overall, 23 studies were identified with a total of 1288 cirrhotic patients of whom 958/1288 underwent endoscopic therapy for acute non-variceal GIB. Peptic ulcer bleeding was the most common cause of acute non-variceal bleeding, followed by portal hypertensive gastropathy, gastric antral vascular ectasia, Mallory-Weiss syndrome, Dieaulafoy lesions, portal hypertensive colopathy, and hemorrhoids. Failure to control bleeding from all-causes of non-variceal GIB accounted for less than 3.5% of cirrhotic patients. Rebleeding (range 2%-25%) and mortality (range 3%-40%) rates varied, presumably due to study heterogeneity. Rebleeding was usually managed endoscopically and salvage therapy using arterial embolisation or surgery was undertaken in very few cases. Mortality was usually associated with liver function deterioration and other organ failure or infections rather than uncontrolled bleeding. Endoscopic treatment-related complications were extremely rare. Lower acute non-variceal bleeding was examined in two studies (197/1288 patients) achieving initial hemostasis in all patients using argon plasma coagulation for portal hypertensive colopathy and endoscopic band ligation or sclerotherapy for bleeding hemorrhoids (rebleeding range 10%-13%). Data on the efficacy of endoscopic therapy of cirrhotic patients vs non-cirrhotic controls with acute GIB are very scarce.
CONCLUSION Endotherapy seems to be efficient as a means to control non-variceal hemorrhage in cirrhosis, although published data are very limited, particularly those comparing cirrhotics with non-cirrhotics and those regarding acute bleeding from the lower gastrointestinal tract. Rebleeding and mortality rates appear to be relatively high, although firm conclusions may not be drawn due to study heterogeneity. Hopefully this review may stimulate further research on this subject and help clinicians administer optimal endoscopic therapy for cirrhotic patients.
Collapse
Affiliation(s)
- Georgios Demetriou
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
| | - Aikaterini Augoustaki
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
| | - Evangelos Kalaitzakis
- Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
| |
Collapse
|
6
|
Peng M, Guo X, Yi F, Shao X, Wang L, Wu Y, Wang C, Zhu M, Bian O, Ibrahim M, Chawla S, Qi X. Endoscopic treatment for gastric antral vascular ectasia. Ther Adv Chronic Dis 2021; 12:20406223211039696. [PMID: 34408826 PMCID: PMC8366108 DOI: 10.1177/20406223211039696] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/22/2021] [Indexed: 02/05/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Mengyuan Peng
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
- Postgraduate College, Jinzhou Medical University, Jinzhou, P.R. China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Fangfang Yi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Xiaodong Shao
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Yanyan Wu
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Chunmei Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Menghua Zhu
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Ou Bian
- Department of No.1 Cadre Ward, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, P.R. China
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Saurabh Chawla
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, Liaoning Province 110840, China
| |
Collapse
|
7
|
McCarty TR, Hathorn KE, Chan WW, Jajoo K. Endoscopic band ligation in the treatment of gastric antral vascular ectasia: a systematic review and meta-analysis. Endosc Int Open 2021; 9:E1145-E1157. [PMID: 34222641 PMCID: PMC8216786 DOI: 10.1055/a-1401-9880] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/15/2021] [Indexed: 01/10/2023] Open
Abstract
Background and study aims While argon plasma coagulation (APC) is the first-line treatment for gastric antral vascular ectasia (GAVE), endoscopic band ligation (EBL) has shown promising results. The aim of this study was to perform a systematic review and meta-analysis to evaluate the effectiveness of EBL for the treatment of GAVE. Methods Individualized search strategies were developed in accordance with PRISMA and MOOSE guidelines through September 1, 2020. Measured outcomes included endoscopic success (defined as GAVE eradication/improvement), change in hemoglobin, transfusion dependency, number of treatment sessions, adverse events, rebleeding, and bleeding-associated mortality. Outcomes were compared among studies evaluating EBL versus APC. Results Eleven studies (n = 393; 59.39 % female; mean age 58.65 ± 8.85 years) were included. Endoscopic success was achieved in 87.84 % [(95 % CI, 80.25 to 92.78); I 2 = 11.96 %] with a mean number of 2.50 ± 0.49 treatment sessions and average of 12.40 ± 3.82 bands applied. For 8 studies comparing EBL (n = 143) versus APC (n = 174), there was no difference in baseline patient characteristics. However, endoscopic success was significantly higher for EBL [OR 6.04 (95 % CI 1.97 to 18.56; P = 0.002], requiring fewer treatment sessions (2.56 ± 0.81 versus 3.78 ± 1.17; P < 0.001). EBL was also associated with a greater increase in post-procedure hemoglobin [mean difference 0.35 (95 % CI 0.07 to 0.62; P = 0.0140], greater reduction in transfusions required [mean difference -1.46 (95 % CI -2.80 to -0.12; P = 0.033], and fewer rebleeding events [OR 0.11 (95 % CI, 0.04 to 0.36); P < 0.001]. There was no difference in adverse events or bleeding-associated mortality ( P > 0.050). Conclusions EBL appears to be safe and effective for treatment of GAVE, with improved outcomes when compared to APC.
Collapse
Affiliation(s)
- Thomas R. McCarty
- Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
| | - Kelly E. Hathorn
- Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
| | - Walter W. Chan
- Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
| | - Kunal Jajoo
- Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
| |
Collapse
|
8
|
Nishino K, Kawanaka M, Suehiro M, Yoshioka N, Nakamura J, Urata N, Tanigawa T, Sasai T, Oka T, Monobe Y, Saji Y, Kawamoto H, Haruma K. Gastric Hyperplastic Polyps after Argon Plasma Coagulation for Gastric Antral Vascular Ectasia in Patients with Liver Cirrhosis: A Case Suggesting the "Gastrin Link Theory". Intern Med 2021; 60:1019-1025. [PMID: 33116013 PMCID: PMC8079916 DOI: 10.2169/internalmedicine.5837-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
We herein report a case of gastric hyperplastic polyps after argon plasma coagulation (APC) for gastric antral vascular ectasia (GAVE) in the antrum of a 65-year-old man with liver cirrhosis and hypergastrinemia induced by long-term proton pump inhibitor (PPI) use. Two years after APC therapy, endoscopy demonstrated multiple gastric polyps in the antrum and angle. A gastric polyp biopsy indicated foveolar epithelium hyperplasia, which was diagnosed as gastric hyperplastic polyps. One year after switching to an H2 blocker antagonist, endoscopy revealed that the polyps and GAVE had disappeared, with normal gastrin levels suggesting that PPI-induced hypergastrinemia had caused gastric hyperplastic polyps after APC therapy, and the polyps had disappeared after discontinuing PPIs.
Collapse
Affiliation(s)
- Ken Nishino
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Japan
| | - Miwa Kawanaka
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Japan
| | - Mitsuhiko Suehiro
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Japan
| | - Naoko Yoshioka
- Department of Hepatology and Pancreatology, Kawasaki Medical School, Japan
| | - Jun Nakamura
- Department of Clinical Pathology and Laboratory, Kawasaki Medical School, Japan
| | - Noriyo Urata
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Japan
| | - Tomohiro Tanigawa
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Japan
| | - Takako Sasai
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Japan
| | - Takahito Oka
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Japan
| | - Yasumasa Monobe
- Department of Pathology, Kawasaki Medical School General Medical Center, Japan
| | | | - Hirofumi Kawamoto
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Japan
| | - Ken Haruma
- Department of General Internal Medicine 2, Kawasaki Medical School General Medical Center, Japan
| |
Collapse
|
9
|
Tamari H, Oka S, Tanaka S, Hiyama Y, Ninomiya Y, Kotachi T, Boda T, Yuge R, Urabe Y, Kitadai Y, Chayama K. Clinical usefulness of combination therapy with polidocanol injection and argon plasma coagulation for gastric antral vascular ectasia. JGH OPEN 2021; 5:465-469. [PMID: 33860097 PMCID: PMC8035473 DOI: 10.1002/jgh3.12517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 02/19/2021] [Indexed: 01/10/2023]
Abstract
Background and Aim Gastric antral vascular ectasia (GAVE) causes gastrointestinal bleeding. The initial treatment for GAVE bleeding is endoscopic hemostasis, and currently, the most performed technique to achieve hemostasis is argon plasma coagulation (APC). However, APC is associated with a high recurrence rate. To overcome this limitation, we examined the outcomes of the combination therapy of APC and polidocanol injection (PDI) for treating GAVE. Methods We retrospectively analyzed the outcomes of 15 consecutive GAVE patients treated with PDI + APC at Hiroshima University Hospital between November 2011 and September 2019 with respect to clinical characteristics, hemostatic efficacy, complications related to treatment, and recurrence rate. Results The mean age of patients (4 men and 11 women) was 74 ± 8.4 years. Patients had comorbidities of liver cirrhosis (seven patients, 47%), chronic renal failure (seven patients, 47%), and autoimmune diseases (seven patients, 47%). Endoscopic hemostasis with PDI + APC was performed in all patients (n = 15). The mean number of PDIs attempted to stop bleeding was 1.5 ± 0.8 (1–4), and the mean number of APCs attempted was 2.1 ± 1.2 (1–5). Complications related to treatment occurred in two patients (14%): ulceration in one patient and hematoma in another patient, both of whom were treated conservatively. Two patients (13%) had recurrences during the follow‐up period (average period, 42 months). Both were cured with additional treatment of PDI only. Conclusion The combination therapy of PDI and APC is effective for GAVE with a low recurrence rate.
Collapse
Affiliation(s)
- Hirosato Tamari
- Department of Endoscopy Hiroshima University Hospital Hiroshima Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism Hiroshima University Hospital Hiroshima Japan
| | - Shinji Tanaka
- Department of Endoscopy Hiroshima University Hospital Hiroshima Japan
| | - Yuichi Hiyama
- Department of Center for Integrated Medical Research Hiroshima University Hospital Hiroshima Japan
| | - Yuki Ninomiya
- Department of Endoscopy Hiroshima University Hospital Hiroshima Japan
| | - Takahiro Kotachi
- Department of Endoscopy Hiroshima University Hospital Hiroshima Japan
| | - Tomoyuki Boda
- Department of Endoscopy Hiroshima University Hospital Hiroshima Japan
| | - Ryo Yuge
- Department of Endoscopy Hiroshima University Hospital Hiroshima Japan
| | - Yuji Urabe
- Division of Regeneration and Medicine Center for Translational and Clinical Research Hiroshima University Hospital Hiroshima Japan
| | - Yasuhiko Kitadai
- Department of Health and Science Prefectural University of Hiroshima Hiroshima Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism Hiroshima University Hospital Hiroshima Japan
| |
Collapse
|
10
|
Song Y, Feng Y, Sun LH, Zhang BJ, Yao HJ, Qiao JG, Zhang SF, Zhang P, Liu B. Role of argon plasma coagulation in treatment of esophageal varices. World J Clin Cases 2021; 9:521-527. [PMID: 33553390 PMCID: PMC7829739 DOI: 10.12998/wjcc.v9.i3.521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/02/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
With the development of endoscopic therapy, argon plasma coagulation (APC) has been widely used by endoscopists. It has many advantages, such as simple to operate, low cost, and minimal invasiveness. Because of its capability of lesion ablation and hemostasis, APC has several indications in the gastrointestinal tract. One of them is esophageal varices. The aim of this review is to summarize the research on APC in this field to provide a reference for clinical practice.
Collapse
Affiliation(s)
- Ying Song
- Department of Gastroenterology, Xi’an Gaoxin Hospital, Xi'an 710032, Shaanxi Province, China
| | - Yuan Feng
- Department of Gastroenterology, Xi’an Gaoxin Hospital, Xi'an 710032, Shaanxi Province, China
| | - Li-Hui Sun
- Department of Gastroenterology, Xi’an Gaoxin Hospital, Xi'an 710032, Shaanxi Province, China
| | - Bo-Jiang Zhang
- Department of Gastroenterology, Xi’an Gaoxin Hospital, Xi'an 710032, Shaanxi Province, China
| | - Hong-Juan Yao
- Department of Gastroenterology, Xi’an Gaoxin Hospital, Xi'an 710032, Shaanxi Province, China
| | - Jing-Gui Qiao
- Department of Gastroenterology, Xi’an Gaoxin Hospital, Xi'an 710032, Shaanxi Province, China
| | - Shu-Fen Zhang
- Department of Gastroenterology, Xi’an Gaoxin Hospital, Xi'an 710032, Shaanxi Province, China
| | - Ping Zhang
- Department of Clinical Medical Affair, Erbe China Ltd., Shanghai 200336, China
| | - Bin Liu
- Department of Clinical Medical Affair, Erbe China Ltd., Shanghai 200336, China
| |
Collapse
|
11
|
Tantau M, Crisan D. Is endoscopic band ligation the gold standard for gastric antral vascular ectasia? Endosc Int Open 2019; 7:E1630-E1631. [PMID: 31790084 PMCID: PMC6877421 DOI: 10.1055/a-1006-2763] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Marcel Tantau
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
- “Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Dana Crisan
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| |
Collapse
|
12
|
Comparative Effectiveness and Safety of Radiofrequency Ablation Versus Argon Plasma Coagulation for Treatment of Gastric Antral Vascular Ectasia: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2019; 53:599-606. [PMID: 29952856 DOI: 10.1097/mcg.0000000000001088] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS Although argon plasma coagulation (APC) is the current standard endoscopic treatment for gastric antral vascular ectasia (GAVE), radiofrequency ablation (RFA) has emerged as an attractive alternative. The aim of this study was to perform a systematic review and meta-analysis to evaluate the comparative effectiveness and safety of RFA and APC in the treatment of GAVE. MATERIALS AND METHODS Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases along with major gastroenterology annual meetings were performed through March 2017. Measured outcomes for comparative effectiveness and safety including improvement in hemoglobin levels, transfusion dependence, number of treatment sessions, complications, follow-up, and author-reported endoscopic success were compared among RFA and APC studies. RESULTS In total, 24 studies (n=508) involving APC and 9 studies (n=104) on RFA were included. Mean age of patients included was comparable in both groups (65.33±7.80 y for APC vs. 66.96±6.23 y for RFA; P=0.98). Pooled mean follow-up was significantly longer for APC compared with RFA (19.52±13.11 vs. 7.43±3.72 mo; P<0.001). In total, 47% of RFA patients were refractory to previous treatment with APC. RFA required fewer mean treatment sessions compared with APC (2.10 vs. 3.39, respectively; P<0.001). RFA resulted in fewer and less severe complications as compared with APC (1.92% vs. 5.12%, respectively; P<0.001). Although the reported endoscopic success was better with RFA compared with APC (97% vs. 66%; P<0.001), the posttreatment pooled hemoglobin increase and reduction in transfusion dependence was higher for APC compared with RFA [weighted mean difference 3.10 g/dL (95% confidence interval, 2.92-3.28) vs. 1.95 g/dL (95% confidence interval, 1.62-2.26); P<0.001; and 88% vs. 66%; P<0.001, for APC and RFA, respectively]. CONCLUSIONS There is limited long-term data on RFA for GAVE; however, available evidence suggests RFA has a comparable efficacy and tolerability compared with APC. In addition, RFA seems to be effective for APC-refractory GAVE patients. Future controlled trials are needed to directly compare treatment efficacy, long-term durability, safety, and cost-effectiveness between these interventions.
Collapse
|
13
|
The Role of Therapeutic Endoscopy in Patients With Cirrhosis-Related Causes of Gastrointestinal Bleeding. Curr Gastroenterol Rep 2018; 20:31. [PMID: 29886513 DOI: 10.1007/s11894-018-0637-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW This article aims to review current therapeutic endoscopic treatments available for the management of gastrointestinal bleeding related to cirrhosis. RECENT FINDINGS Endoscopic band ligation is an effective treatment for primary prophylaxis, acute bleeding, and secondary prophylaxis of esophageal varices as well as for acute bleeding and secondary prophylaxis of select gastric varices. Sclerotherapy is a treatment option for acute bleeding and secondary prophylaxis of esophageal varices when band ligation is technically difficult. Cyanoacrylate glue injection is an effective treatment for acute bleeding of gastric and ectopic varices. Argon plasma coagulation is first-line and radiofrequency ablation is second-line treatment for chronic bleeding secondary to gastric antral vascular ectasia. There are a variety of endoscopic treatment modalities for cirrhosis-related gastrointestinal bleeding, and the appropriate therapy depends on the location of the bleed, history or presence of acute bleeding, and risk factors for intervention-related adverse events.
Collapse
|
14
|
Hsu WH, Wang YK, Hsieh MS, Kuo FC, Wu MC, Shih HY, Wu IC, Yu FJ, Hu HM, Su YC, Wu DC. Insights into the management of gastric antral vascular ectasia (watermelon stomach). Therap Adv Gastroenterol 2018; 11:1756283X17747471. [PMID: 29399041 PMCID: PMC5788127 DOI: 10.1177/1756283x17747471] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/30/2017] [Indexed: 02/04/2023] Open
Abstract
Gastric antral vascular ectasia (GAVE) is an uncommon but important cause of chronic gastrointestinal bleeding. It is often associated with systemic diseases such as autoimmune diseases, liver cirrhosis, chronic renal insufficiency and cardiovascular disease. The etiology of GAVE has not been fully explored and remains controversial. Diagnosis is mainly based on endoscopic presentation with flat or raised erythematous stripes radiating from the pylorus to the antrum and resembles a watermelon. Clinical presentation may range from iron-deficiency anemia secondary to occult blood loss, melena to hematemesis. In past decades, many therapeutic modalities including medical, endoscopic and surgical intervention have been introduced for GAVE treatment with variable efficacy. Herein, we review the efficacy and safety of these treatment options for GAVE.
Collapse
Affiliation(s)
- Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yao-Kuang Wang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
| | - Meng-Shu Hsieh
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Fu-Chen Kuo
- Shool of Medicine, College of Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Meng-Chieh Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Hsiang-Yao Shih
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - I-Chen Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Fang-Jung Yu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Huang-Ming Hu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Chung Su
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, TaiwanDepartment of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | |
Collapse
|
15
|
Endoscopic variceal ligation combined with argon plasma coagulation versus ligation alone for the secondary prophylaxis of variceal bleeding: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2017; 29:621-628. [PMID: 28195875 DOI: 10.1097/meg.0000000000000861] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic variceal ligation (EVL) is often recommended as an effective method for the treatment of esophageal varices, despite the important tendency of variceal recurrence. Recent studies indicate that combining EVL with argon plasma coagulation (APC) may be a more effective therapy than ligation alone. To investigate these findings, we carried out a systematic review and meta-analysis to compare the safety and efficacy of EVL combined with APC versus ligation alone for the secondary prophylaxis of esophageal variceal hemorrhage. All studies were searched through PubMed, the Cochrane Library, and Science Direct. The outcome measures were relative risk (RR) or risk difference with 95% confidence intervals (CIs) for dichotomous data and standardized mean difference for continuous data. Heterogeneity was calculated using the χ and the I-tests. Two investigators independently identified four randomized-controlled trials included in the research. The variceal recurrence rate was significantly lower in the combined therapy group (RR=0.19, 95% CI: 0.09-0.41, P=0.000). The bleeding recurrence and mortalities in the two groups showed no significant differences (RR=0.29, 95% CI: 0.08-1.04, P=0.058; risk difference=-0.02, 95% CI: -0.08-0.04, P=0.576, respectively). Although the pyrexia incidence rate was significantly higher in the combined group (RR=3.42, 95% CI: 1.56-7.48, P=0.002), there was intertrial heterogeneity (I=52.5%, P=0.097). EVL combined with APC is superior to ligation alone for endoscopic variceal recurrence without severe adverse events in secondary prophylaxis against esophageal variceal bleeding. More high-quality studies are needed to strengthen this conclusion.
Collapse
|
16
|
Gkamprela E, Deutsch M, Pectasides D. Iron deficiency anemia in chronic liver disease: etiopathogenesis, diagnosis and treatment. Ann Gastroenterol 2017; 30:405-413. [PMID: 28655976 PMCID: PMC5479992 DOI: 10.20524/aog.2017.0152] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 03/21/2017] [Indexed: 12/21/2022] Open
Abstract
Chronic liver disease is accompanied by multiple hematological abnormalities. Iron deficiency anemia is a frequent complication of advanced liver disease. The etiology is multifactorial, mostly due to chronic hemorrhage into the gastrointestinal tract. The diagnosis of iron deficiency anemia is very challenging, as simple laboratory methods, including serum iron, ferritin, transferrin saturation (Tsat), and mean corpuscular volume are affected by the liver disease itself or the cause of the disease, resulting in difficulty in the interpretation of the results. Several new parameters, such as red blood cell ferritin, serum transferrin receptor test and index, and hepcidin, have been studied for their utility in indicating true iron deficiency in combination with chronic liver disease. Once iron deficiency anemia is diagnosed, it should be treated with oral or parenteral iron as well as portal pressure reducing drugs. Blood transfusion is reserved for symptomatic anemia despite iron supplementation.
Collapse
Affiliation(s)
- Eleana Gkamprela
- Second Department of Internal Medicine, University of Athens, Hippokration General Hospital, Athens
| | - Melanie Deutsch
- Second Department of Internal Medicine, University of Athens, Hippokration General Hospital, Athens
| | - Dimitrios Pectasides
- Second Department of Internal Medicine, University of Athens, Hippokration General Hospital, Athens
| |
Collapse
|
17
|
Zepeda-Gómez S. Endoscopic Treatment for Gastric Antral Vascular Ectasia: Current Options. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 24:176-182. [PMID: 29255747 DOI: 10.1159/000453271] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/04/2016] [Indexed: 01/10/2023]
Abstract
Gastric antral vascular ectasia (GAVE) is a capillary-type vascular malformation located primarily in the gastric antrum. Patients can present with iron-deficiency anemia, overt gastrointestinal bleeding, or both. Diagnosis and characterization is made at endoscopic examination, and the preferred management of patients with GAVE is endoscopic therapy. Herein, we present a review of the evidence about the efficacy, complications, and outcomes of the most frequently used endoscopic therapies for GAVE.
Collapse
|
18
|
Mendonca EQ, de Oliveira JF, Maluf-Filho F. Argon plasma coagulation and radiofrequency ablation in nonvariceal upper gastrointestinal bleeding. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2016. [DOI: 10.1016/j.tgie.2016.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|
19
|
Garg H, Gupta S, Anand AC, Broor SL. Portal hypertensive gastropathy and gastric antral vascular ectasia. Indian J Gastroenterol 2015; 34:351-8. [PMID: 26564121 DOI: 10.1007/s12664-015-0605-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 10/17/2015] [Indexed: 02/04/2023]
Abstract
Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are gastric mucosal lesions that mostly present as chronic anemia and rarely cause the acute gastrointestinal hemorrhage. Despite similar clinical manifestations, their pathophysiology and management are entirely different. PHG is seen exclusively in patients with portal hypertension, but GAVE can also be observed in patients with other conditions. Their diagnosis is endoscopic, and although generally each of them has a characteristic endoscopic appearance and distribution, there are cases in which the differential is difficult and must rely on histology. This review focuses on the management of both entities. The mainstay of management of PHG is based on portal-hypotensive pharmacological treatment while GAVE benefits from hormonal therapy, endoscopic Nd:YAG laser, and argon plasma coagulation. More invasive options should be reserved for refractory cases.
Collapse
Affiliation(s)
- Hitendra Garg
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India.
| | - Subhash Gupta
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India
| | - A C Anand
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India
| | - S L Broor
- Center for Liver and Biliary Disease, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India.,Gastroenterology and Hepatology, Indra Prastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi, 110 076, India
| |
Collapse
|
20
|
Tjwa ETTL, Holster IL, Kuipers EJ. Endoscopic management of nonvariceal, nonulcer upper gastrointestinal bleeding. Gastroenterol Clin North Am 2014; 43:707-19. [PMID: 25440920 DOI: 10.1016/j.gtc.2014.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Upper gastrointestinal bleeding (UGIB) is the most common emergency condition in gastroenterology. Although peptic ulcer and esophagogastric varices are the predominant causes, other conditions account for up to 50% of UGIBs. These conditions, among others, include angiodysplasia, Dieulafoy and Mallory-Weiss lesions, gastric antral vascular ectasia, and Cameron lesions. Upper GI cancer as well as lesions of the biliary tract and pancreas may also result in severe UGIB. This article provides an overview of the endoscopic management of these lesions, including the role of novel therapeutic modalities such as hemostatic powder and over-the-scope-clips.
Collapse
Affiliation(s)
- Eric T T L Tjwa
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, PO box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - I Lisanne Holster
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, PO box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, PO box 2040, 3000 CA, Rotterdam, The Netherlands
| |
Collapse
|
21
|
Baptista V, Marya N, Singh A, Rupawala A, Gondal B, Cave D. Continuing challenges in the diagnosis and management of obscure gastrointestinal bleeding. World J Gastrointest Pathophysiol 2014; 5:523-533. [PMID: 25400996 PMCID: PMC4231517 DOI: 10.4291/wjgp.v5.i4.523] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/28/2014] [Accepted: 07/17/2014] [Indexed: 02/06/2023] Open
Abstract
The diagnosis and management of obscure gastrointestinal bleeding (OGIB) have changed dramatically since the introduction of video capsule endoscopy (VCE) followed by deep enteroscopy and other imaging technologies in the last decade. Significant advances have been made, yet there remains room for improvement in our diagnostic yield and treatment capabilities for recurrent OGIB. In this review, we will summarize the latest technologies for the diagnosis of OGIB, limitations of VCE, technological enhancement in VCE, and different management options for OGIB.
Collapse
|
22
|
Patwardhan VR, Cardenas A. Review article: the management of portal hypertensive gastropathy and gastric antral vascular ectasia in cirrhosis. Aliment Pharmacol Ther 2014; 40:354-62. [PMID: 24889902 DOI: 10.1111/apt.12824] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/12/2014] [Accepted: 05/14/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are important causes of both acute and chronic gastrointestinal bleeding in patients with cirrhosis. AIM To review the current management of PHG and GAVE. METHODS PubMed was searched for English language articles using the key words 'GAVE', 'gastric antral vascular ectasia', 'cirrhosis', 'gastrointestinal bleeding', 'acute', 'chronic', 'portal hypertensive gastropathy', 'watermelon stomach', 'radiofrequency ablation', 'band ligation', 'thermoablation' and 'TIPSS'. RESULTS GAVE and PHG are both encountered in patients with cirrhosis. They can be seen in asymptomatic patients and in those with either acute or chronic gastrointestinal bleeding. PHG, by definition, requires the presence of portal hypertension, with or without cirrhosis, whereas GAVE requires neither cirrhosis nor portal hypertension. They can often be diagnosed on endoscopic appearance alone, but may require biopsy in certain cases. The treatment of PHG is aimed at reducing hepatic venous pressure gradients, most often by pharmacologic means, but may require shunt procedures in severe cases. Management of GAVE on the other hand is predominantly endoscopic, focusing on various ablative techniques. CONCLUSIONS Gastric antral vascular ectasia and portal hypertensive gastropathy are distinct entities and are both encountered in cirrhotic patients. Management of portal hypertensive gastropathy is centred on reduction in portal pressures, whereas treatment of gastric antral vascular ectasia is predominantly endoscopic.
Collapse
|
23
|
Naidu H, Huang Q, Mashimo H. Gastric antral vascular ectasia: the evolution of therapeutic modalities. Endosc Int Open 2014; 2:E67-73. [PMID: 26135263 PMCID: PMC4423327 DOI: 10.1055/s-0034-1365525] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 01/08/2014] [Indexed: 01/10/2023] Open
Abstract
Gastric Antral Vascular Ectasia (GAVE) may be an enigmatic source of non-variceal upper GI bleeding associated with various systemic diseases such as connective tissue disorders, liver disease, and chronic renal failure. Successful treatment of GAVE continues to be a challenge and has evolved through the years. 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. However, other newer ablative modalities such as radiofrequency ablation, cryotherapy, and band ligations are promising. This paper is an overview of GAVE and its various endoscopic and medical therapies.
Collapse
Affiliation(s)
- Harini Naidu
- Department of Internal Medicine, Boston University Medical Center, Boston, Massachusetts, United States,Corresponding author Harini Naidu, MD Department of Internal MedicineBoston University Medical Center72 East Concord StreetEvans 124BostonMA 02118United States
| | - Qin Huang
- Department of Gastroenterology, VA Boston Healthcare System, Boston, Massachusetts, United States,Department of Pathology, Harvard Medical School, Boston, Massachusetts, United States
| | - Hiroshi Mashimo
- Department of Gastroenterology, VA Boston Healthcare System, Boston, Massachusetts, United States,Department of Pathology, Harvard Medical School, Boston, Massachusetts, United States
| |
Collapse
|
24
|
Swanson E, Mahgoub A, MacDonald R, Shaukat A. Medical and endoscopic therapies for angiodysplasia and gastric antral vascular ectasia: a systematic review. Clin Gastroenterol Hepatol 2014; 12:571-82. [PMID: 24013107 DOI: 10.1016/j.cgh.2013.08.038] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 07/24/2013] [Accepted: 08/19/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Few studies have compared the efficacy and complications of endoscopic or medical therapies for bleeding angiodysplasias or gastric antral vascular ectasias (GAVE). We conducted a systematic review to evaluate therapies. METHODS We performed a PubMed search for studies (written in English from January 1, 1980, through January 1, 2013) of medical or endoscopic treatment of bleeding angiodysplasias and GAVE. Measured outcomes included levels of hemoglobin, transfusion requirements, rebleeding rates, complications, treatment failures, and overall mortality. RESULTS We analyzed data from 63 studies that met inclusion criteria; 50 evaluated endoscopic treatment (1790 patients), 13 evaluated medical treatment (392 patients), and 12 were comparative studies. In patients with angiodysplasias, the combination of estrogen and progesterone did not significantly reduce bleeding episodes, compared with placebo (0.7/y vs 0.9/y, respectively), and increased mortality, compared with conservative therapy (33% vs 21%). A higher percentage of patients receiving octreotide were free of rebleeding at 1 and 2 years vs placebo (77% vs 55% and 68% vs 36%, respectively; P = .03). Thalidomide reduced the number of bleeding episodes (-8.96/y), compared with iron therapy (-1.38/y, P < .01), but neither treatment reduced mortality. More patients with GAVE treated by endoscopic band ligation were free from rebleeding (92%) than those treated with argon plasma coagulation (32%, P = .01). CONCLUSIONS In a systematic review, we found a low quality of evidence to support treatment of angiodysplasias with thalidomide or the combination of estrogen and progesterone and insufficient evidence to support treatment with octreotide. There is also insufficient evidence for endoscopic therapy of angiodysplasia or GAVE. Well-designed randomized controlled trials are needed to study the efficacy and complications of medical and endoscopic treatments for patients with angiodysplasias or GAVE.
Collapse
Affiliation(s)
- Eric Swanson
- Department of Medicine, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota
| | - Amar Mahgoub
- Department of Medicine, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota; Section of Gastroenterology, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota
| | - Roderick MacDonald
- Minnesota Evidence based Practice Center, Center for Chronic Disease and Outcome Research, Minneapolis, Minnesota
| | - Aasma Shaukat
- Department of Medicine, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota; Section of Gastroenterology, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota.
| |
Collapse
|
25
|
Kwak HW, Lee WJ, Woo SM, Kim BH, Park JW, Kim CM, Kim TH, Han SS, Kim SH, Park SJ, Kook MC. Efficacy of argon plasma coagulation in the treatment of radiation-induced hemorrhagic gastroduodenal vascular ectasia. Scand J Gastroenterol 2014; 49:238-45. [PMID: 24286663 DOI: 10.3109/00365521.2013.865783] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Radiation-induced hemorrhagic gastroduodenal vascular ectasia (GDVE) is rare but difficult to manage. Argon plasma coagulation (APC) has not yet been evaluated in the treatment of radiation-induced hemorrhagic GDVE. The efficacy of APC in patients with radiation-induced hemorrhagic GDVE has been investigated in this article. MATERIAL AND METHODS Eighteen patients with upper gastrointestinal (GI) bleeding caused by radiation-induced GDVE, including 13 with hepatocellular carcinoma, 3 with pancreatic cancer, and 2 with cholangiocarcinoma, were treated with APC. The efficacy of APC was retrospectively evaluated, based on cessation of macroscopic GI bleeding, resolution or stabilization of anemia and transfusion dependence, endoscopic ablation of almost all vascular lesions, complications, and recurrence. RESULTS Mean patient age was 59 years (range 42-80 years). The median time from radiation to GDVE diagnosis was 4.6 months (range 3.3-21.5 months). The median number of APC sessions per patient was 2.4 (range 1-4). All 18 patients showed an endoscopic response to APC treatment, with sustained increases in mean hemoglobin level, from 6.6 g/dL (range 2.9-9.5 g/dL) to 9.7 g/dL (range 7.1-12.7 g/dL) (p < 0.001), and decreased dependence on transfusion, from 9.1 (range 0-30) to 4.1 (range 0-15) units of packed red blood cells per patient (p = 0.038) after last endoscopic eradication by APC treatment. There were no major procedure-related adverse events or deaths. At a median follow up of 4.7 months (range 0.6-24.5 months), none of the patients experienced recurrence of GDVE. CONCLUSIONS APC showed short-term effectiveness and safety in the treatment of radiation-induced hemorrhagic GDVE.
Collapse
Affiliation(s)
- Hee-Won Kwak
- Center for Liver Cancer, National Cancer Center , Goyang , Korea
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Yoshida H, Takahashi H, Akoshima H, Chida N, Noguchi K, Tanabe N, Mano Y, Ukai K, Tadokoro K. Successful treatment of refractory gastric antral vascular ectasia using transcatheter arterial embolization. Clin J Gastroenterol 2013; 6:231-6. [DOI: 10.1007/s12328-013-0385-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 04/30/2013] [Indexed: 12/11/2022]
|
27
|
Post-transplant gastric antral vascular ectasia after intra-venous busulfan regimen. Int J Hematol 2013; 98:135-8. [PMID: 23632949 DOI: 10.1007/s12185-013-1342-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 04/13/2013] [Accepted: 04/15/2013] [Indexed: 12/11/2022]
Abstract
Gastric antral vascular ectasia (GAVE) is an angiodysplastic disorder that causes gastric bleeding. GAVE can develop as a complication of hematopoietic stem cell transplantation (HSCT-GAVE), and it has been suggested that it may be associated with oral administration of busulfan. We report two cases of HSCT-GAVE after a conditioning regimen containing intra-venous busulfan (ivBu), not oral busulfan. The first case, a 42-year-old woman with blastic plasmacytoid dendritic cell neoplasm, underwent second allogeneic HSCT with conditioning regimen consisting of cyclophosphamide (120 mg/kg) and ivBu (12.8 mg/kg). HSCT-GAVE developed on day 84 post-transplant, and argon plasma coagulation (APC) was performed successfully. The second case, a 60-year-old woman with acute myelogenous leukemia, underwent allogeneic HSCT with the conditioning regimen consisting of ivBu (12.8 mg/kg) and fludarabine (150 mg/kg). She developed melena and was diagnosed with GAVE by endoscopy on day 145 post-transplant. Although complete hemostasis was not achieved despite four administrations of APCs, the melena spontaneously terminated on day 235 post-transplant. To our knowledge, this is the first report describing HSCT-GAVE after ivBU-based HSCT. Although there is no established therapy for HSCT-GAVE, APC may be an option for HSCT-GAVE.
Collapse
|
28
|
Fuccio L, Mussetto A, Laterza L, Eusebi LH, Bazzoli F. Diagnosis and management of gastric antral vascular ectasia. World J Gastrointest Endosc 2013; 5:6-13. [PMID: 23330048 PMCID: PMC3547119 DOI: 10.4253/wjge.v5.i1.6] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 09/26/2012] [Accepted: 12/01/2012] [Indexed: 02/05/2023] Open
Abstract
Gastric antral vascular ectasia (GAVE) is an uncommon but often severe cause of upper gastrointestinal (GI) bleeding, responsible of about 4% of non-variceal upper GI haemorrhage. The diagnosis is mainly based on endoscopic pattern and, for uncertain cases, on histology. GAVE is characterized by a pathognomonic endoscopic pattern, mainly represented by red spots either organized in stripes radially departing from pylorus, defined as watermelon stomach, or arranged in a diffused-way, the so called honeycomb stomach. The histological pattern, although not pathognomonic, is characterized by four alterations: vascular ectasia of mucosal capillaries, focal thrombosis, spindle cell proliferation and fibrohyalinosis, which consist of homogeneous substance around the ectatic capillaries of the lamina propria. The main differential diagnosis is with Portal Hypertensive Gastropathy, that can frequently co-exists, since about 30% of patients with GAVE co-present a liver cirrhosis. Autoimmune disorders, mainly represented by Reynaud’s phenomenon and sclerodactyly, are co-present in about 60% of patients with GAVE; other autoimmune and connective tissue disorders are occasionally reported such as Sjogren’s syndrome, systemic lupus erythematosus, primary biliary cirrhosis and systemic sclerosis. In the remaining cases, GAVE syndrome has been described in patients with chronic renal failure, bone marrow transplantation and cardiac diseases. The pathogenesis of GAVE is still obscure and many hypotheses have been proposed such as mechanical stress, humoural and autoimmune factors and hemodynamic alterations. In the last two decades, many therapeutic options have been proposed including surgical, endoscopic and medical choices. Medical therapy has not clearly shown satisfactory results and surgery should only be considered for refractory severe cases, since this approach has significant mortality and morbidity risks, especially in the setting of portal hypertension and liver cirrhosis. Endoscopic therapy, particularly treatment with Argon Plasma Coagulation, has shown to be as effective and also safer than surgery, and should be considered the first-line treatment for patients with GAVE-related bleeding.
Collapse
Affiliation(s)
- Lorenzo Fuccio
- Lorenzo Fuccio, Liboria Laterza, Leonardo Henry Eusebi, Franco Bazzoli, Department of Clinical Medicine, S.Orsola-Malpighi University Hospital, 40138 Bologna, Italy
| | | | | | | | | |
Collapse
|
29
|
Non-variceal gastrointestinal bleeding in patients with liver cirrhosis: a review. Dig Dis Sci 2012; 57:2743-54. [PMID: 22661272 DOI: 10.1007/s10620-012-2229-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 05/01/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Non-variceal gastrointestinal (NVGI) bleeding in cirrhosis may be associated with life-threatening complications similar to variceal bleeding. AIM To review NVGI bleeding in cirrhosis. METHODS 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." RESULTS 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. CONCLUSIONS 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.
Collapse
|
30
|
Short-term effect of argon plasma coagulation on chronic blood loss due to portal hypertensive gastropathy in cirrhotic patients. EGYPTIAN LIVER JOURNAL 2012. [DOI: 10.1097/01.elx.0000419584.92981.b0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
|
31
|
Marsteller WF, Lewin DN, Reuben A. The biopsy GAVE the diagnosis. Clin Gastroenterol Hepatol 2012; 10:e75-6. [PMID: 22200686 DOI: 10.1016/j.cgh.2011.12.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 12/08/2011] [Accepted: 12/12/2011] [Indexed: 02/07/2023]
Affiliation(s)
- William F Marsteller
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | |
Collapse
|
32
|
Chiu YC, Lu LS, Wu KL, Tam W, Hu ML, Tai WC, Chiu KW, Chuah SK. Comparison of argon plasma coagulation in management of upper gastrointestinal angiodysplasia and gastric antral vascular ectasia hemorrhage. BMC Gastroenterol 2012; 12:67. [PMID: 22681987 PMCID: PMC3439282 DOI: 10.1186/1471-230x-12-67] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 06/09/2012] [Indexed: 01/10/2023] Open
Abstract
Background Vascular ectasias, including gastric antral vascular ectasia (GAVE) and angiodysplasia, are increasingly recognized as important sources of gastrointestinal bleeding. This study investigated and compared the efficacies and outcomes of treatment of upper gastrointestinal (UGI) angiodysplasia and GAVE hemorrhage by endoscopic argon plasma coagulation (APC). Methods From January 2006 to December 2009, 46 patients diagnosed with upper GI bleeding caused by angiodysplasia or GAVE at a tertiary hospital were recruited into this study. They included 26 males and 20 females with an average age of 65.6 years (range, 45–90 years). All patients underwent APC for hemostasis during an endoscopic procedure. Parameters such as underlying co-morbidities, number of endoscopic treatment sessions, recurrent bleeding, and clinical outcomes during follow-up were analyzed. Results The 46 patients with UGI vascular ectasia hemorrhage included 27 patients with angiodysplasia and 19 with GAVE. The patients with angiodysplasia were older than those with GAVE (71.6 ± 10.2 years versus 61.8 ± 11.9 years, P = 0.005). More GAVE patients than angiodysplasia patients had co-existing liver cirrhosis (63.2% versus 25.9%, P = 0.012). The patients with GAVE had a higher rate of recurrent bleeding (78.9% versus 7.4%, P < 0.001) and required more treatment sessions to achieve complete hemostasis (2.4 ± 1.4 versus 1.1 ± 0.1, P < 0.001) than those with angiodysplasia. Univariate analysis demonstrated that age greater than 60 years (odds ratio (OR) = 8.929, P = 0.003), GAVE (OR = 0.021, P < 0.001), and previous radiation therapy (OR = 11.667, P = 0.032) were associated with higher rates of recurrent bleeding. Further multivariate analysis revealed that GAVE was the only independent risk factor for recurrent bleeding after APC treatment (OR = 0.027, P < 0.001). Conclusion Endoscopic hemostasis with APC is a safe treatment modality for both angiodysplasia and vascular ectasia bleeding. The efficacy of APC treatment is greater for angiodysplasia than for vascular ectasia bleeding. GAVE patients have a higher recurrent bleeding rate and may require multiple treatment sessions for sustained hemostasis.
Collapse
Affiliation(s)
- Yi-Chun Chiu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung City 833, Taiwan
| | | | | | | | | | | | | | | |
Collapse
|
33
|
Krystallis C, Masterton GS, Hayes PC, Plevris JN. Update of endoscopy in liver disease: More than just treating varices. World J Gastroenterol 2012; 18:401-11. [PMID: 22346246 PMCID: PMC3272639 DOI: 10.3748/wjg.v18.i5.401] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 06/02/2011] [Accepted: 06/09/2011] [Indexed: 02/06/2023] Open
Abstract
The management of complications in liver disease is often complex and challenging. Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease. In this review, relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension. The main areas covered are safety of endoscopy in patients with liver disease, the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound, esophageal capsule, argon plasma coagulation, spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology. It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices. As the technology in endoscopy expands, so does the role of the endoscopist in liver disease.
Collapse
|
34
|
Ripoll C, Garcia-Tsao G. The management of portal hypertensive gastropathy and gastric antral vascular ectasia. Dig Liver Dis 2011; 43:345-51. [PMID: 21095166 DOI: 10.1016/j.dld.2010.10.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 10/11/2010] [Indexed: 02/08/2023]
Abstract
Portal hypertensive gastropathy and gastric antral vascular ectasia are gastric mucosal lesions that can cause chronic gastrointestinal haemorrhage and, consequently, chronic anaemia, in patients with cirrhosis. Although chronic anaemia is the most common clinical manifestation, these entities may also lead to acute gastrointestinal bleeding. Despite similar clinical manifestations, their pathophysiology and management are entirely different. Their diagnosis is endoscopic and although generally each of them has a characteristic endoscopic appearance and distribution, there are cases in which the differential is difficult and must rely on histology. This review focuses on the management of both entities. The mainstay of management of portal hypertensive gastropathy is based on portal-hypotensive pharmacological treatment whilst gastric antral vascular ectasia benefits from endoscopic therapy. More invasive options should be reserved for refractory cases.
Collapse
Affiliation(s)
- Cristina Ripoll
- Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | | |
Collapse
|
35
|
Naga M, Esmat S, Naguib M, Sedrak H. Long-term effect of argon plasma coagulation (APC) in the treatment of gastric antral vascular ectasia (GAVE). Arab J Gastroenterol 2011; 12:40-3. [PMID: 21429455 DOI: 10.1016/j.ajg.2011.01.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 09/09/2010] [Accepted: 11/24/2010] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND STUDY AIMS Gastric antral vascular ectasia (GAVE) is a distinct vascular abnormality, mainly involving the gastric antrum. It is a rare but well-known cause of occult gastrointestinal bleeding. Various endoscopic treatment modalities have been tried in this condition. The aim of the study is to show the long-term effect of argon plasma coagulation (APC) on GAVE. PATIENTS AND METHODS Twenty-nine patients with endoscopically proved GAVE were enrolled in the study. Clinical assessment of GAVE patients, haemoglobin (Hb) level and transfused blood units were recorded after APC using 60-80-W power setting. A second session was done 1month after the therapeutic procedure to ensure complete ablation of all lesions. RESULTS The documented Hb levels and number of blood units transfused 3months after APC were recorded. At endoscopy, all patients had the classic type of GAVE. The mean Hb level increased from 7.5±1.7gdl(-1) before APC to 10.2±0.8gdl(-1) after APC (p value <0.001). The transfusion requirements significantly decreased to 0.2±0.5units/patient (p value <0.001). CONCLUSION Endoscopic APC is a safe, effective and inexpensive modality in treating GAVE and could be an alternative to the currently available endoscopic methods.
Collapse
Affiliation(s)
- Mazen Naga
- Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | | | | | | |
Collapse
|
36
|
Bittencourt PL, Farias AQ, Strauss E, Mattos AAD. Variceal bleeding: consensus meeting report from the Brazilian Society of Hepatology. ARQUIVOS DE GASTROENTEROLOGIA 2010; 47:202-16. [PMID: 20721469 DOI: 10.1590/s0004-28032010000200017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 08/17/2009] [Indexed: 02/06/2023]
Abstract
In the last decades, several improvements in the management of variceal bleeding have resulted in a significant decrease in morbidity and mortality of patients with cirrhosis and bleeding varices. Progress in the multidisciplinary approach to these patients has led to a better management of this disease by critical care physicians, hepatologists, gastroenterologists, endoscopists, radiologists and surgeons. In this respect, the Brazilian Society of Hepatology has, recently, sponsored a consensus meeting in order to draw evidence-based recommendations on the management of these difficult-to-treat subjects. An organizing committee comprised of four people was elected by the Governing Board and was responsible to invite 27 researchers from distinct regions of the country to make a systematic review of the subject and to present topics related to variceal bleeding, including prevention, diagnosis, management and treatment, according to evidence-based medicine. After the meeting, all participants met together for discussion of the topics and the elaboration of the aforementioned recommendations. The organizing committee was responsible for writing the final document. The meeting was held at Salvador, May 6th, 2009 and the present manuscript is the summary of the systematic review that was presented during the meeting, organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.
Collapse
|
37
|
Ripoll C, Garcia-Tsao G. Management of gastropathy and gastric vascular ectasia in portal hypertension. Clin Liver Dis 2010; 14:281-95. [PMID: 20682235 PMCID: PMC2916868 DOI: 10.1016/j.cld.2010.03.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Portal hypertensive gastropathy and gastric antral vascular ectasia may cause gastrointestinal hemorrhage in patients with portal hypertension. Whereas the former presents exclusively in patients with portal hypertension, gastric antral vascular ectasia can also be observed in patients with other conditions. Diagnosis is established with upper gastrointestinal endoscopy, although some cases may require a biopsy to confirm the diagnosis. The most frequent manifestation is ferropenic anemia, which may become transfusion dependent. Treatment in portal hypertensive gastropathy is focused on portal pressure reducing drugs, mainly nonselective beta-blockers, whereas in gastric antral vascular ectasia treatment is based on endoscopic ablation. More invasive options can be used if first-line therapies fail, although these should be evaluated on a case-by-case basis.
Collapse
Affiliation(s)
| | - Guadalupe Garcia-Tsao
- Corresponding author: Guadalupe Garcia-Tsao, M.D., Digestive Diseases Section, Yale University School of Medicine, 333 Cedar Street – 1080 LMP, New Haven, CT 06510, , Tph: 203 737 6063, Fax: 203 785-7273
| |
Collapse
|
38
|
CD61, CD31, and CD34 improve diagnostic accuracy in gastric antral vascular ectasia and portal hypertensive gastropathy: An immunohistochemical and digital morphometric study. Am J Surg Pathol 2010; 34:494-501. [PMID: 20351488 DOI: 10.1097/pas.0b013e3181d38f0a] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are unusual but important causes of gastrointestinal bleeding with characteristic endoscopic appearances and critically different therapies. However, overlapping features and poor endoscopic-histologic correlation make their distinction challenging. We sought to determine whether CD31, CD34 (vascular markers), and CD61 (platelet marker) could aid in their differentiation. Cases included 11 antral specimens with histologic diagnoses of GAVE, 11 histologically diagnosed as PHG, and biopsies of GAVE (15) or PHG (12) suspected on endoscopy but without histologic agreement. Controls consisted of endoscopically and histologically normal antrum. Image analysis of CD31 and CD34-stained sections was performed to determine mucosal microvessel density (MVD). CD61 revealed thrombi in 100% of histologically confirmed cases of GAVE and 60% of cases suspected of GAVE on endoscopy alone; control biopsies were negative. CD61 was also positive in 26% of cases originally signed out as PHG. Review of hematoxylin and eosin slides from these CD61-positive PHG cases showed other features allowing their correct reclassification as GAVE. MVD was significantly higher in GAVE than PHG. MVD in histologically confirmed PHG did not differ significantly from endoscopically suspected PHG. Review of hematoxylin and eosin slides from the latter showed active gastritis obscuring recognition of ectatic vessels. In conclusion, CD61 reliably differentiates GAVE from PHG. MVD analysis can also assist in their distinction. In PHG, the increased vascularity may be subtle in an inflammatory background; vascular markers may serve as adjunct markers for identifying the aberrant vessels.
Collapse
|
39
|
Argon photocoagulation in the treatment of gastric antral vascular ectasia and radiation proctitis. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2010; 23:801-4. [PMID: 20011731 DOI: 10.1155/2009/374138] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
Collapse
|