A case of gastric antral vascular ectasia treated with argon plasma coagulation.
Yong-Mock BaeEul-Jo JeongJeong HeoKwang-Ha KimHyung-Jun ChuDae-Hwan KangMong ChoUng-Suk YangChang Hun Lee
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Abstract:
Gastric antral vascular ectasia (GAVE) is a rare but important cause of chronic gastrointestinal bleeding. Endoscopically, it has characteristic thickened red vascular folds radiating from the pylorus to the antrum. Diagnosis is made primarily by endoscopy. Histologic examination of the endoscopic mucosal biopsies may confirm the endoscopic diagnosis. Many treatment modalities of the gastric antral vascular ectasia exist. One of them, the argon plasma coagulation (APC) is an excellent therapeutic tool. Inactive argon gas is converted to ionized form by means of electrical energy. Ionized argon plasma conducts high frequency electrical energy to tissues and leads coagulation necrosis of tissues. We experienced a case of gastric antral vascular ectasia presenting melena for about one month in a 72-year-old man treated endoscopically in four sessions with argon plasma coagulation.Keywords:
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患者は59歳，男性．平成14年1月，胸部中部食道扁平上皮癌の診断で，右開胸開腹食道亜全摘術を施行した．胸骨後経路，頸部吻合，大彎側細径胃管再建を行った．なお，術前の上部消化管内視鏡検査で胃に異常は認められなかった．その後，外来通院していたが，平成15年5月，上部消化管内視鏡検査で，再建胃管内に放射状に延長する縦長の発赤帯を認めたが，毛細血管の拡張は明らかではなかった．平成16年5月の上部消化管内視鏡検査では，発赤帯の毛細血管の拡張を認めた．平成17年3月の外来採血時，著明な貧血を認め，上部消化管内視鏡検査で，胃前庭部毛細血管拡張症（GAVE）からの出血と診断し，内視鏡下アルゴンプラズマ凝固療法を実施した．GAVEは消失し，胃粘膜の再生上皮化により治癒した．その後，出血の再発は認められていない．再建胃管に発生した胃前庭部毛細血管拡張症は非常に稀であり，若干の文献的考察を加え報告する．
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Purpose: 56-year-old Caucasian male with end-stage liver disease secondary to previous alcohol abuse complicated with ascites and transfusion dependent GAVE was evaluated for a transplant. The pre-transplant upper endoscopy showed severe GAVE in the antrum, and a fleshy, nodular geographic mass with crevices and indentations in the 1st part of the duodenum. EUS and biopsies of the mass were obtained since, nodularity is an atypical pattern for GAVE. EUS showed thickened mucosa and submucosa up to 12 mm without focal mass, muscularis propria abnormality or adenopathy. Biopsy of the lesion showed vascular ectasia with thrombosis confirming duodenal GAVE. Serial APC and IV iron therapy did not improve his transfusion requirements. Orthotopic Liver Transplantation was performed in June 2009 and following this, there were no further transfusion requirements. Endoscopy done a year after the transplantation showed complete resolution of the antral GAVE and duodenal nodular mass. Discussion: GAVE is a distinct entity with characteristic endoscopic and pathologic criteria, most often associated with liver cirrhosis. It is now generally accepted that portal hypertension is not a key factor because surgical or endovascular portosystemic shunts do not improve GAVE. The mechanism by which the diseased liver induces GAVE is speculative, but it can be hypothesized that there is an accumulation of substances not metabolized by the diseased liver, which may induce vasodilatation of gastric veins, stimulate angiogenesis, or both. Glucagon, gastrin and nitric oxide are logical candidate substances because they are increased in patients with severe cirrhosis and normalize after transplantation. Treatment of GAVE induced recurrent bleeding often is challenging; APC, estrogen and in refractory cases, surgical antrectomy are therapeutic options. Our case shows an unusual presentation of GAVE as a nodular mass and that, when it induces recurrent bleeding in cirrhotic patients, liver transplantation can be curative.
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BACKGROUND: Gastric antral vascular ectasia is a disorder whose pathogenetic mechanism is unknown. The endoscopic treatment with argon plasma coagulation has been considered one of the best endoscopic therapeutic options. AIM: To analyze the endoscopic and clinical features of gastric antral vascular ectasia and its response to the argon plasma coagulation treatment. PATIENTS AND METHODS: Eighteen patients were studied and classified into two groups: group 1 - whose endoscopic aspect was striped (watermelon) or of the diffuse confluent type; group 2 - diffuse spotty nonconfluent endoscopic aspect. RESULTS: Group 1 with eight patients, all having autoimmune antibodies, but one, whose antibodies were not searched for. Three were cirrhotic and three had hypothyroidism. All had gastric mucosa atrophy. In group 2, with 10 patients, all had non-immune liver disease, with platelet levels below 90.000. Ten patients were submitted to argon plasma coagulation treatment, with 2 to 36 months of follow-up. Lesions recurred in all patients who remained in the follow-up program and one did not respond to treatment for acute bleeding control. CONCLUSION: There seem to be two distinct groups of patients with gastric antral vascular ectasia: one related to immunologic disorders and other to non-immune chronic liver disease and low platelets. The endoscopic treatment using argon plasma coagulation had a high recurrence in the long-term evaluation.
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Argon plasma coagulation treatment of Gastric Antral Vascular Ectasia (GAVE): a review of four cases
Antral vascular ectasia (“watermelon stomach”) has recently been defined and characterized. This condition may be a source of significant bleeding from the stomach. Although steroids have been useful in some patients, antrectomy has been advocated as definitive therapy. We have treated 12 patients who were bleeding from this lesion with the Olympus HeatProbe Unit® and have eliminated further hemorrhage. All presented with gastrointestinal bleeding, iron-deficiency anemia, and compatible antral biopsies. Using the large probe, vascular streaks were treated until the endoscopic appearance returned to normal (average four treatment sessions). No further bleeding was evident from the antral vascular ectasia over an average follow-up period of 20.9 months. Eight of 10 patients who had required transfusion prior to therapy no longer needed transfusion, but two received blood for other conditions. We conclude that antral vascular ectasia can be successfully treated with the HeatProbe Unit® and this should be the initial modality of therapy for this condition.
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