Gastric antral vascular ectasia

Gastric antral vascular ectasia
Other names	Watermelon stomach, watermelon disease
Endoscopic image of gastric antral vascular ectasia seen as a radial pattern around the pylorus before (top) and after (bottom) treatment with argon plasma coagulation
Specialty	Gastroenterology
Symptoms	Bleeding in the stomach and intestines, edema, dilated blood vessels

Gastric antral vascular ectasia (GAVE) is an uncommon cause of chronic

The condition was first discovered in 1952,[2] and reported in the literature in 1953.^[5] Watermelon disease was first diagnosed by Wheeler et al. in 1979, and definitively described in four living patients by Jabbari et al. only in 1984.^[4] As of 2011, the cause and pathogenesis are still not known.^[4][6] However, there are several competing hypotheses as to various causes.^[4]

Signs and symptoms

Most patients who are eventually diagnosed with watermelon stomach come to a physician complaining of anemia and blood loss.^[7] Sometimes, a patient may come to the physician because he or she notices blood in the stools—either melena (black and tarry stools) and/or hematochezia (red bloody stools).^[7]

Cause

The literature, from 1953 through 2010, often cited that the cause of gastric antral vascular ectasia is unknown.^[4][6][7] The causal connection between cirrhosis and GAVE has not been proven.^[6] A connective tissue disease has been suspected in some cases.^[7]

Autoimmunity may have something to do with it,^[8] as 25% of all sclerosis patients who had a certain anti-RNA marker have GAVE.^[9] RNA autoimmunity has been suspected as a cause or marker since at least 1996.^[8] Gastrin levels may indicate a hormonal connection.^[6]

Associated conditions

GAVE is associated with a number of conditions, including

Watermelon stomach also occurs particularly with scleroderma,^{[2][12][13][14]} and especially the subtype known as systemic sclerosis.^[2][9] A full 5.7% of persons with sclerosis have GAVE, and 25% of all sclerosis patients who had a certain anti-RNA polymerase marker have GAVE.^[9] In fact:

Most patients with GAVE suffer from liver cirrhosis, autoimmune disease, chronic kidney failure and bone marrow transplantation. The typical initial presentations range from occult bleeding causing transfusion-dependent chronic iron-deficiency anemia to severe acute gastrointestinal bleeding.

— Masae Komiyama, et al., 2010.^[10]

The endoscopic appearance of GAVE is similar to

The first case of ectopic pancreas associated with watermelon stomach was reported in 2010.^[4]

Patients with GAVE may have elevated gastrin levels.^[6]

The Genetic and Rare Diseases Information Center (GARD) states that pernicious anemia is one of the conditions associated with GAVE,^[18] and one separate study showed that over three-fourths of the patients in the study with GAVE had some kind of vitamin B₁₂ deficiency including the associated condition pernicious anemia.^[19]

Intestinal permeability and diverticulitis may occur in some patients with GAVE.

Pathogenesis

GAVE is characterized by dilated capillaries in the

GAVE is usually diagnosed definitively by means of an endoscopic biopsy.^{[6][7][10][20]} The tell-tale watermelon stripes show up during the endoscopy.^[7]

Surgical exploration of the abdomen may be needed to diagnose some cases, especially if the liver or other organs are involved.^[4]

Differential diagnosis

GAVE results in intestinal bleeding similar to

Watermelon stomach has a different etiology and has a differential diagnosis from portal hypertension.^[6][15] In fact, cirrhosis and portal hypertension may be missing in a patient with GAVE.^[6] The differential diagnosis is important because treatments are different.^{[3][6][7][10]}

Treatment

Traditional treatments

GAVE is treated commonly by means of an endoscope, including

If there is cirrhosis of the liver that has progressed to liver failure, then lactulose may be prescribed for hepatic encephalopathy, especially for Type C encephalopathy with diabetes.^[24] Also, "antibiotics such as neomycin, metronidazole, and rifaximin" may be used effectively to treat the encephalopathy by removing nitrogen-producing bacteria from the gut.^[24]

Paracentesis, a medical procedure involving needle drainage of fluid from a body cavity,^[25] may be used to remove fluid from the peritoneal cavity in the abdomen for such cases.^[23] This procedure uses a large needle, similar to the better-known amniocentesis.

Surgery

Surgery, consisting of excision of part of the lower stomach, also called antrectomy, is another option.

A treatment used sometimes is endoscopic band ligation.[27]

In 2010, a team of Japanese surgeons performed a "novel endoscopic ablation of gastric antral vascular ectasia".^[10] The experimental procedure resulted in "no complications".^[10]

Relapse is possible, even after treatment by argon plasma coagulation and progesterone.^[21]

Antrectomy or other surgery is used as a last resort for GAVE.^{[2][6][7][10][15][16][excessive citations]}

Epidemiology

The average age of diagnosis for GAVE is 73 years of age for females,^[3][7] and 68 for males.^[2] Women are about twice as often diagnosed with gastric antral vascular ectasia than men.^[2][7] 71% of all cases of GAVE are diagnosed in females.^[3][7] Patients in their thirties have been found to have GAVE.^[6] It becomes more common in women in their eighties, rising to 4% of all such gastrointestinal conditions.^[10]

5.7% of all sclerosis patients (and 25% of those who had a certain anti-RNA marker) have GAVE.^[9]

References