OMED E-Newsletter Issue 3, 2009: Brainteaser/image of the month
This was found in a 55 year old man undergoing upper digestive endoscopy for iron deficiency anaemia.
Which of the following is NOT a recognised association?
- hypergastrinaemia
- portal hypertension
- liver disease without portal hypertension
- systemic sclerosis
- bile reflux
Explanation
The correct answer is e. Gastric antral vascular ectasia "GAVE" or "GVE" (watermelon stomach) has been described with atrophic gastritis, achlorhydria/hypergastrinaemia, connective tissue diseases (especially systemic sclerosis?) and chronic renal failure. One study suggested that a "punctuate pattern" was typical of cirrhosis whilst a "striped type" was more common in non-cirrhotic cases. Portal hypertensive gastropathy is probably a distinct condition as gastric antral vascular ectasia can develop with a normal portal pressure. Patients usually present with iron deficiency anaemia.
There is no need to biopsy as the endoscopic appearance is pathognomonic. However, if the endoscopist has taken a biopsy, the histology may show dilated and thrombosed capillaries in the lamina propria with fibromuscular hyperplasia. However, these changes are non-specific.
The initial therapy should be endoscopic cautery, preferably the APC. For cases with more extensive post-radiotherapy telangiectasia, oral sucralfate, topical phenol and formalin has been described.
Patients with bleeding from GAVE were previously treated with antrectomy. Now, the first line treatment is “thermal therapy”. Octeotride and oestrogen-progesterone have also been used in small series but would now only be considered if endoscopic therapy fails. It is far easier to treat these lesions using the argon coagulator than the heater probe. When the ectasia radiates towards the pylorus, it is possible to withdraw the probe along the line of ectasia as argon is deployed. Below is an example of the result at the end of such a treatment session.
I was recently referred a case of GAVE who had failed attempts at endoscopic ablation. However, with two weekly treatments for two months (each taking about 25 minutes), it proved possible to destroy all ectatic lesions. With patience it is likely that all lesions can be managed endoscopically.