What is the treatment for gastric antral vascular ectasia (GAVE)?

Treatment of Gastric Antral Vascular Ectasia (GAVE)

Endoscopic band ligation (EBL) is the preferred first-line treatment for gastric antral vascular ectasia, showing superior outcomes with fewer treatment sessions and better improvement in hemoglobin levels compared to thermal therapies. 1

Understanding GAVE

Gastric antral vascular ectasia (GAVE), also known as "watermelon stomach," is characterized by:

• Distinctive endoscopic appearance with red spots organized in stripes radiating from the pylorus (watermelon pattern) or arranged in a diffuse pattern (honeycomb stomach) 2
• Common associations with cirrhosis (30% of cases), autoimmune disorders (60%), chronic renal failure, and cardiac diseases 2
• Causes approximately 4% of non-variceal upper GI bleeding 2
• Often results in chronic blood loss leading to iron deficiency anemia and need for repeated transfusions

Diagnostic Approach

• Diagnosis is primarily based on characteristic endoscopic appearance
• Upper endoscopy is the gold standard diagnostic procedure
• Histological findings (not pathognomonic but supportive):
  • Vascular ectasia of mucosal capillaries
  • Focal thrombosis
  • Spindle cell proliferation
  • Fibrohyalinosis around ectatic capillaries 2

Treatment Algorithm

First-Line Treatment:

1. Endoscopic Band Ligation (EBL)
   • Superior efficacy compared to thermal methods
   • Requires fewer sessions (mean 2.63 vs 3.83 for thermal methods)
   • Greater improvement in hemoglobin levels (mean improvement 0.59 g/dL higher than thermal methods)
   • Better reduction in transfusion requirements (difference in mean transfusions -2.30 favoring EBL)
   • Favorable safety profile 1

Alternative Endoscopic Options:

1. Argon Plasma Coagulation (APC)

   • Traditional first-line approach
   • Success rate: 40-100%
   • Requires multiple sessions
   • High recurrence rate: 10-78.9%
   • Potential adverse events: hyperplastic polyps, sepsis, Mallory-Weiss syndrome 3

2. Radiofrequency Ablation (RFA)

   • Success rate: 90-100%
   • Recurrence rate: 21.4-33.3%
   • Adverse events similar to APC 3

For Refractory Cases:

• Multimodal Approach for nodular GAVE variants:

  • Combination of techniques (e.g., submucosal injection of 1% Polidocanol followed by APC) 4, 5

• Surgical Antrectomy:

  • Reserved for severe refractory cases
  • Higher mortality and morbidity risk, especially in patients with portal hypertension or cirrhosis 2

Iron Replacement Therapy

All patients with GAVE and iron deficiency anemia should receive iron repletion:

• May be oral or intravenous depending on severity of iron depletion and tolerance 1

Special Considerations

Portal Hypertension

• Important to differentiate GAVE from Portal Hypertensive Gastropathy (PHG)
• 30% of GAVE patients have concurrent liver cirrhosis 2
• Unlike PHG, GAVE does not respond to portal pressure reduction therapies 1

Monitoring and Follow-up

• Follow-up endoscopy to assess treatment response
• Monitor hemoglobin levels and transfusion requirements
• Success of treatment measured by:
  • Improvement in endoscopic appearance
  • Increase in hemoglobin levels
  • Reduction in transfusion requirements 6, 5

Treatment Efficacy Metrics

• Mean pre-treatment hemoglobin: 8.2 g/dL
• Mean post-treatment hemoglobin: 9.7 g/dL
• Mean reduction in blood transfusions: from 3.8 to 1.2 units 5

Pitfalls to Avoid

• Misdiagnosis of GAVE as PHG (30% coexistence)
• Inadequate number of treatment sessions
• Failure to recognize refractory cases requiring multimodal approach
• Delaying treatment, leading to chronic anemia and transfusion dependence
• Overlooking associated conditions (cirrhosis, autoimmune disorders) that may affect treatment outcomes