Gastric Antral Vascular Ectasia (GAVE): An Update on Clinical Presentation, Pathophysiology and Treatment

Abstract

Gastric antral vascular ectasia (GAVE), though a rare disorder, causes up to 4% of non-variceal upper GI bleeding. This paper gives an overview of studies examining clinical presentation and pathophysiology, and reviews the current evidence for invasive and non-invasive treatments. GAVE is often associated with systemic illnesses, such as cirrhosis of the liver, autoimmune connective tissue disorders, bone marrow transplantation and chronic renal failure. The pathophysiological changes leading to GAVE have not been fully explained and remain controversial. Patient presentation varies from chronic iron-deficiency anaemia to heavy acute gastrointestinal bleeding. It is important to differentiate GAVE from portal hypertensive gastropathy as GAVE does not respond to measures reducing portal pressures. Endoscopic ablation (Nd:YAG-laser or argon plasma coagulation) is the first-line treatment of choice. As evidence for pharmacological therapy with oestrogen (and/or progesterone), tranexamic acid or thalidomide stems from case reports only, these should be used if endoscopic measures have failed to stop chronic blood loss. Surgical antrectomy should be reserved for unresponsive cases as it is associated with a high mortality. Ultimately, treatment of the underlying medical co-morbidities may lead to resolution of GAVE.

Massive gastric antral vascular ectasia successfully treated by endoscopic band ligation as the initial therapy

“…This condition was firstly reported as "an erosive type of gastritis with marked veno-cappillary ectasia" by Rider et al [1,2] in 1953. Up to the present, there had been more data regarding of the epidemiology, pathology including the outcomes of variable treatment modalities for this condition [1] . Interestingly, there have been many hypotheses regarded the pathophysiology of GAVE which seem to be linked to cirrhosis or portal hypertension.…”

“…Interestingly, there have been many hypotheses regarded the pathophysiology of GAVE which seem to be linked to cirrhosis or portal hypertension. By the way, the other theories such as GAVE and achlorhydria or mechanical stress at the antral area thus caused the detachment of the distal gastric mucosa to the pyloric ring were still be under investigated [1] . Considering the treatment options for GAVE, the non-endoscopic treatment which aimed to reduce the bleeding without ablative therapy such as beta-blocker, octreotide, Thalidomide or even tranexamic acid reported of only little benefit.…”

Watermelon stomach, hemorrhagic pericarditis, small cell carcinoma of the lung and synchronous squamous cell carcinoma of the tongue base

“…Since GAVE is not acid related pharmacotherapy with histamine receptor antagonists and proton pump inhibitors is ineffective. Evidence for effective pharmacologic therapy with oestrogen (and/or progesterone), tranexamic acid or thalidomide, are mentioned in some case reports only 6 . Ultimately, treatment of any underlying medical comorbidities may lead to resolution of GAVE 6 .…”

“…Evidence for effective pharmacologic therapy with oestrogen (and/or progesterone), tranexamic acid or thalidomide, are mentioned in some case reports only 6 . Ultimately, treatment of any underlying medical comorbidities may lead to resolution of GAVE 6 . Many authors consider endoscopic therapy as the primary therapy, namely argon plasma coagulation (APC), which appears to be preferable in comparison with contact methods (heater probe, electrocautery with bipolar electrocoagulation probe, or Gold probe) or other noncontact ablative modality (Nd:YAG laser).…”

“…rare disorder, GAVE is responsible for roughly 4% of non-variceal upper gastrointestinal bleeding 6 . Profuse gastric hemorrhage is rare with this disorder but may occur as a result of superimposed bleeding diathesis which is present in the majority of patients reporting melena, and is determined by the concomitant presence of conditions such as biliary cirrhosis, valvular heart disease, congestive heart failure, nonsteroidal anti-inflammatory use, CREST syndrome and systemic sclerosis, and chronic renal insufficiency, which can occur in association with watermelon stomach 3 .…”