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Vascular ectasia of gastric antrum — Clinical Guidelines

Overview

Gastric antral vascular ectasia (GAVE), also known as "watermelon stomach," is a rare condition characterized by dilated blood vessels in the gastric antrum, leading to chronic or acute gastrointestinal bleeding and iron deficiency anemia 1 7.

Diagnosis

Endoscopic appearance: Characteristic bright red, longitudinal stripes resembling a watermelon 1 7.

Diagnostic tests: Upper endoscopy is definitive; capsule endoscopy may identify GAVE in patients with obscure gastrointestinal bleeding 3.

Biopsy findings: Typically not required for diagnosis but may show mucosal vascularity, fibromuscular hyperplasia, and inflammatory changes 10.

Associated conditions: Often linked with liver cirrhosis, portal hypertension, and hypergastrinemia 2 5 9.

Management

First-line treatments:

- Endoscopic modalities: Argon plasma coagulation (APC), band ligation, and laser therapy (neodymium:yttrium-aluminium-garnet) 1 6 8.

Adjunctive treatments:

- Medications: Continuous or intermittent octreotide for bleeding control 1. - TIPS (Transjugular Intrahepatic Portosystemic Shunt): Considered in patients with portal hypertension 5. - Bevacizumab: Off-label use at 7.5 mg/kg every three weeks shown effective in refractory cases 1.

Special Populations

Liver cirrhosis: Increased risk and challenging management; TIPS and bevacizumab may be considered 1 5.

Hypergastrinemia: Discontinuation of PPIs can lead to resolution of associated gastric hyperplastic polyps 2.

Key Recommendations

Primary treatment with endoscopic modalities such as APC or laser therapy for GAVE to control bleeding and stabilize hemoglobin levels (Evidence: Moderate 6 8).

Use of octreotide for continuous or intermittent infusion to manage refractory bleeding (Evidence: Weak 1).

Consider TIPS insertion in patients with portal hypertension and refractory bleeding (Evidence: Weak 5).

Evaluate off-label bevacizumab in cases of severe, refractory bleeding unresponsive to conventional treatments (Evidence: Weak 1).

References

1 Gairing SJ, Schleicher EM, Müller L, Labenz C, Darstein F, Grimm D et al.. Bevacizumab in combination with octreotide rescues a patient with liver cirrhosis, GAVE syndrome and refractory hemorrhage - a case report. Zeitschrift fur Gastroenterologie 2023. link 2 Nishino K, Kawanaka M, Suehiro M, Yoshioka N, Nakamura J, Urata N et al.. Gastric Hyperplastic Polyps after Argon Plasma Coagulation for Gastric Antral Vascular Ectasia in Patients with Liver Cirrhosis: A Case Suggesting the "Gastrin Link Theory". Internal medicine (Tokyo, Japan) 2021. link 3 Sidhu R, Sanders DS, McAlindon ME. Does capsule endoscopy recognise gastric antral vascular ectasia more frequently than conventional endoscopy?. Journal of gastrointestinal and liver diseases : JGLD 2006. link 4 Abedi M, Haber GB. Watermelon stomach. The Gastroenterologist 1997. link 5 Egger C, Kreczy A, Kirchmair R, Waldenberger P, Jaschke W, Vogel W. Gastric antral vascular ectasia with portal hypertension: treatment with TIPSS. The American journal of gastroenterology 1997. link 6 Bourke MJ, Hope RL, Boyd P, Gillespie PE, Ward M, Cowen AE et al.. Endoscopic laser therapy for watermelon stomach. Journal of gastroenterology and hepatology 1996. link 7 Berry DM. Gastric antral vascular ectasia (watermelon stomach). Gastroenterology nursing : the official journal of the Society of Gastroenterology Nurses and Associates 1995. link 8 Park RH, Danesh BJ, Upadhyay R, Howatson AG, Lee FD, Russell RI. Gastric antral vascular ectasia (watermelon stomach)--therapeutic options. Postgraduate medical journal 1990. link 9 Lowes JR, Rode J. Neuroendocrine cell proliferations in gastric antral vascular ectasia. Gastroenterology 1989. link91437-6) 10 Suit PF, Petras RE, Bauer TW, Petrini JL. Gastric antral vascular ectasia. A histologic and morphometric study of "the watermelon stomach". The American journal of surgical pathology 1987. link

Vascular ectasia of gastric antrum