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

Treatment of Watermelon Stomach (Gastric Antral Vascular Ectasia)

Endoscopic thermal ablation, particularly argon plasma coagulation (APC), is the first-line treatment for watermelon stomach (gastric antral vascular ectasia or GAVE syndrome). This approach provides the best balance of efficacy, safety, and minimally invasive management for this condition 1.

Understanding Watermelon Stomach

Watermelon stomach is characterized by:

• Distinctive endoscopic appearance of longitudinal red stripes in the gastric antrum resembling a watermelon
• Histologically shows superficial fibromuscular hyperplasia with capillary ectasia and microvascular thrombosis
• Commonly causes chronic occult gastrointestinal blood loss leading to iron deficiency anemia
• Often requires blood transfusions if untreated
• May be associated with portal hypertension in some cases, though the exact relationship is unclear 2

Treatment Algorithm

First-Line Treatment:

• Endoscopic thermal ablation therapy
  • Argon plasma coagulation (APC) is preferred due to:
    • Limited depth of penetration (reducing perforation risk)
    • Symmetric spread of coagulation effects
    • Lower cost compared to laser devices 3
    • High initial success rate in controlling bleeding and reducing transfusion requirements 4
  • Multiple sessions (average 2-3) are typically required for complete treatment 4
  • Follow-up endoscopy should be performed every 2-4 weeks until complete obliteration 2

For Persistent/Recurrent Bleeding After Endoscopic Therapy:

• Pharmacologic options (limited evidence):
  • Tranexamic acid 500mg twice daily, gradually increasing to 1000mg four times daily for mild-moderate bleeding 5
  • For severe cases with portal hypertension: consider non-selective beta-blockers to reduce portal pressure 2

For Refractory Cases:

• Surgical antrectomy should be considered when:
  • Patient fails to respond to repeated endoscopic therapy
  • Transfusion dependence persists
  • Recurrent bleeding episodes continue 1, 6

Monitoring and Follow-up

• Monitor hemoglobin levels regularly
• Iron supplementation for patients with anemia 5
• After endoscopic eradication, repeat endoscopic assessment within 3-6 months and then yearly thereafter 2
• For recurrent GAVE on long-term follow-up (>12 months), consider cross-sectional imaging to evaluate for underlying portal hypertension 2

Special Considerations

• Approximately 40% of patients may experience recurrence after initial successful treatment with APC, requiring additional sessions 4
• Patients with chronic kidney disease on hemodialysis may have more severe presentations requiring more aggressive management 7
• In cases associated with portal hypertension, addressing the underlying portal hypertension may be necessary in addition to local therapy 2

Treatment Pitfalls to Avoid

• Delaying surgical intervention after failed endoscopic therapy can lead to prolonged transfusion dependence and chronic anemia
• Misdiagnosis as portal hypertensive gastropathy, which has a different treatment approach
• Failure to provide adequate iron supplementation between treatments
• Inadequate endoscopic follow-up, as recurrence is common

Early recognition and prompt treatment of watermelon stomach are essential to prevent chronic blood loss, reduce transfusion requirements, and improve quality of life for affected patients.