Hemorrhage from Extra-Antral Gastric Antral Vascular Ectasia in a Patient with Duodenal Heterotopic Gastric Mucosa

Abstract

Gastric antral vascular ectasias (GAVE) have been increasingly recognized as an uncommon cause of chronic gastrointestinal bleeding and anemia, although their underlying pathogenesis is not completely well understood. Heterotopic gastric mucosa (HGM) has been reported to occur at various sites along the gastrointestinal tract and although relatively common, it is often asymptomatic. We report a case of a 60-year-old woman with a prior history of GAVE who developed melena and symptomatic anemia during her hospitalization following cardiac catheterization. Initial EGD demonstrated nonbleeding antral GAVE and a newly discovered duodenal mass. Duodenal mass biopsies were ultimately notable for HGM along with histologic features of extra-antral GAVE. The patient required blood transfusions and consequently had a small bowel endoscopy notable for fresh blood in the proximal small bowel. The patient underwent a small bowel push enteroscopy which demonstrated active bleeding of the duodenal mass and overlying oozing GAVE, which was cauterized with Argon-Plasma Coagulation with adequate hemostasis. We present for the first time a novel association between GAVE and HGM. Our case illustrates that extra-antral GAVE may occur with HGM in the duodenum. We explore potential mechanisms by which HGM may be involved in the pathogenesis of GAVE.

Life-threatening gastrointestinal bleeding caused by jejunal heterotopic gastric mucosa in an adult dog: a rare case report

“…In both, human and veterinary medicine, HGM is a rare finding, being mostly incidental during endoscopy or necropsy [ 16 , 23 ]. Most often patients are asymptomatic on presentation, however, several cases of patients that presented minor to severe symptoms, ranging from vomiting, chronic anemia, rectal bleeding, melena, intussusception and abdominal pain have been reported [ 3 , 7 , 11 – 13 , 15 ].…”

“…Heterotopic mucosa is defined as morphologically normal tissue displaced in a foreign anatomical site, separated from its organ of origin and demarcated from surrounding mucosa [1]. Heterotopic gastric mucosa (HGM), gastric tissue that is found outside the stomach, has been described in human medicine in several case reports [2][3][4][5][6][7][8][9][10][11][12][13][14]. It has been reported in children [15] and in adults [9] with most patients being alive at the time of diagnosis.…”

“…The prevalence in human medicine is estimated to be 0.1% up to 11% [9] whilst the prevalence in veterinary medicine has been reported to be 4.1% in dogs in a single study [16]. In human medicine, HGM has been found in different locations, including esophagus [4,9,19,20], duodenum [7] anorectum [8], gall bladder and cystic duct [3], airways [21], and in congenital abnormalities such as Meckel's diverticulum and gastrointestinal duplications [22]. In contrast, HGM has been described only in the intestine of dogs and in the esophagus of cats [16][17][18].…”

“…In both, human and veterinary medicine, HGM is a rare finding, being mostly incidental during endoscopy or necropsy [16,23]. Most often patients are asymptomatic on presentation, however, several cases of patients that presented minor to severe symptoms, ranging from vomiting, chronic anemia, rectal bleeding, melena, intussusception and abdominal pain have been reported [3,7,[11][12][13]15]. This case report is the first to present a life-threatening gastrointestinal hemorrhage, that required whole blood transfusion, caused by HGM in the jejunum of an adult dog.…”