What is the management of Gastric Antral Vascular Ectasia (GAVE)?

Management of Gastric Antral Vascular Ectasia (GAVE)

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

First-Line Management

Endoscopic Treatment Options

1. Endoscopic Band Ligation (EBL)

   • Requires fewer sessions (mean 2.63 vs 3.83 for thermal methods) 2
   • Results in greater improvement in hemoglobin levels (mean difference 0.59 g/dL higher than thermal methods) 2
   • Lower transfusion requirements (difference in mean transfusions: -2.30) 2
   • Favorable safety profile with rare and mild adverse events 3

2. Argon Plasma Coagulation (APC)

   • Traditionally considered first-line endoscopic treatment 3
   • Endoscopic success rate of 40-100% 3
   • Requires multiple treatment sessions
   • Higher recurrence rate (10-78.9%) 3
   • Potential adverse events include hyperplastic gastric polyps, sepsis, and Mallory-Weiss syndrome 3

3. Radiofrequency Ablation (RFA)

   • Alternative for refractory cases
   • Endoscopic success rate of 90-100% 3
   • Recurrence rate of 21.4-33.3% 3
   • Can be effective in APC-refractory cases 4

Iron Replacement Therapy

• All patients with GAVE and iron deficiency anemia should receive iron repletion 2, 1
• Iron therapy may be oral or intravenous depending on:
  • Severity of iron depletion
  • Patient tolerance 2
  • Response to therapy

Management Algorithm

1. Initial Diagnosis

   • Confirm GAVE through endoscopic evaluation
   • Distinguish from portal hypertensive gastropathy (PHG)
   • Note: GAVE does not respond to portal pressure reduction therapies, unlike PHG 1

2. First-Line Treatment

   • Proceed with EBL as the preferred treatment 2, 1
   • Schedule repeat endoscopic sessions every 2-4 weeks until obliteration is complete

3. For Refractory Cases

   • Consider alternative endoscopic modalities:
     • RFA (90-100% success rate) 3, 4
     • Cryotherapy 5

4. Concurrent Management

   • Initiate iron replacement therapy 2, 1
   • Monitor hemoglobin levels and transfusion requirements

5. Follow-up

   • Schedule endoscopic reassessment after treatment completion
   • Monitor for recurrence (8.3-48.1% with EBL) 3

Special Considerations

• Associated Conditions: GAVE is commonly associated with cirrhosis, systemic sclerosis, chronic kidney disease, and other conditions 2, 6
• Surgical Approach: Consider surgical intervention (antrectomy) only when endoscopic therapies fail 3, 5
• TIPSS: Transjugular intrahepatic portosystemic stent-shunt does not have a role in the management of bleeding solely from GAVE 2

Treatment Success Evaluation

• Improvement in endoscopic appearance
• Increase in hemoglobin levels
• Reduction in transfusion requirements 1
• Approximately 80% of patients can become transfusion-free after completion of endoscopic treatment 4

Pitfalls and Caveats

1. Misdiagnosis: Important to differentiate GAVE from portal hypertensive gastropathy (PHG) as management differs significantly 2
2. Recurrence: High recurrence rates necessitate follow-up endoscopy and potential retreatment 3
3. Treatment Selection: While APC has traditionally been used, evidence now supports EBL as superior in terms of efficacy and required treatment sessions 2, 1
4. Portal Hypertension: TIPSS is not effective for GAVE, even when associated with cirrhosis, as GAVE does not respond to portal pressure reduction 2