Gastric antral vascular ectasia is an uncommon cause of chronic gastrointestinal bleeding or iron deficiency anaemia [1]. The condition is associated with dilated small blood vessels in the antrum, or the last part of the stomach. It is also called watermelon stomach because streaky long red areas that are present in the stomach may resemble the markings on watermelon [2]. GAVE is associated with a number of conditions, including portal hypertension, chronic renal failure and collagen vascular diseases particularly scleroderma. GAVE is treated with treatment through the endoscope, including argon plasma coagulation and electrocautery. Other medical treatments have been tried and include estrogen and progesterone therapy and anti-fibrinolytic drugs such as tranexamic acid.
2. Case ReportThe 69 years old woman was first admitted to our Department due to severe gastrointestinal bleeding. In her previous history, she had tonsillectomy, cholecystectomy and heart failure. In laboratory analysis she had severe anemia. During upper gastrointestinal endoscopy in total intravenous anesthesia, the features of GAVE were apparent (Picture 1) We arranged access to argon plasma coagulation (Picture 2) With a total number of 7 sessions of APC, we managed to prolong the out-of-hospital periods and thereby somewhat decrease the RBC transfusion consumption. Tranexamic acid were included.
3. DiscussionGastrointestinal endoscopic procedure has become an essential modality for evaluation and management of gastrointestinal tract abnormalities. The safe sedation (TIVA) of patients for this procedure requires a combination of properly trained physicians and appropriate facilites. Moreover, proper selection and preparation of patients, suitable sedative tehnique, and application of drugs is essential. The use of short acting drug, adequate dose of sedative agents and sedation endpoint as well as appropriate sedation tehnique has an important role and also increased the safety [3, 4]. Gastric antral vascular ectasia was first described in a patient with severe chronic iron-defiency anaemia. Gastroscopy showed a grey smooth mucosa of the corpum. In contrast, the antrum was reported to be hypertrophic mucosal changes, adherent old blood and scattered areas of profuse bleeding were also noted. Microscopy revealed a chronic inflammation and an oedematous submucosa with large, dilated veins. This condition was described as an erosive type of gastritis with marked veno-capillary ectasia. A more accurate definition defined GAVE as longitudinal antral folds converging on the pylorus, containing visible columns of tortuous red ectatic vessels. Histological appearances were described as hyperplasia of the mucosa with capillary ectasia and thrombosis, fibromuscular hyperplasia of the lamina propria and abnormal vessels in the submucosa. In accordance with the endoscopic appearance, which resembled the stripes on a watermelon, they dubbed the condition watermelon stomach. GAVE is a rare entity, but is found in about 4% of all non-variceal upper gastrointestinal bleeding. The real incidence remains unknown as only symptomatic patients will undergo gastroscopy and then be diagnosed. Furthermore, the tendency to bleed is probably overestimated as most studies reporting on GAVE are subject to selection bias.
4. ConclusionTreatment options for GAVE include endoscopic ablation (argon plasma coagulation), surgical antrectomy or pharmacological therapy with oestrogen (and / or progesterone), tranexamic acid or thalidomide.
References
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Sanja Vickovic. Uncommon Cause of Gastrointestinal Bleeding. Annals of Clinical and Medical Case Reports 2021