What are the treatment options for Gastric Antral Vascular Ectasia (GAVE)?

Treatment Options for Gastric Antral Vascular Ectasia (GAVE)

Endoscopic therapy is the preferred first-line treatment for GAVE, with endoscopic band ligation (EBL) showing superior outcomes compared to thermal methods in reducing transfusion requirements and improving hemoglobin levels. 1

Understanding GAVE

• GAVE is an uncommon but significant cause of chronic gastrointestinal blood loss, often associated with conditions like cirrhosis, chronic kidney disease, and systemic sclerosis 1
• It presents with characteristic endoscopic findings of parallel red stripes resembling watermelon stripes in the gastric antrum 2
• GAVE can lead to iron deficiency anemia and overt gastrointestinal bleeding, requiring intervention 3

First-Line Treatment: Endoscopic Approaches

Endoscopic Band Ligation (EBL)

• EBL is currently the most effective endoscopic treatment for GAVE based on comparative studies 1
• Advantages over thermal methods include:
  • Greater reduction in transfusion requirements (difference in mean transfusions: -2.30) 1
  • More pronounced improvement in hemoglobin levels (difference in mean improvement: 0.59 g/dL) 1
  • Fewer endoscopic sessions needed to achieve obliteration (mean 2.63 vs 3.83 sessions) 1
  • Favorable safety profile with rare and mild adverse events such as nausea, vomiting, and abdominal pain 4
• EBL has endoscopic success rates of 77.8-100% with recurrence rates of 8.3-48.1% 4

Argon Plasma Coagulation (APC)

• Traditionally considered first-line endoscopic treatment for GAVE 4
• Endoscopic success rate ranges from 40-100% 4
• Limitations include:
  • Requires multiple treatment sessions 4
  • High recurrence rate (10-78.9%) 4
  • Potential adverse events include hyperplastic gastric polyps, sepsis, and Mallory-Weiss syndrome 4

Radiofrequency Ablation (RFA)

• Increasingly used as an alternative for refractory GAVE 4
• High endoscopic success rates of 90-100% 4
• Recurrence rates of 21.4-33.3% 4
• Particularly useful in patients who have failed APC treatment 5
• Technical success rate of approximately 95% in refractory cases 5

Follow-Up and Management Protocol

• After endoscopic treatment, regular follow-up endoscopy is necessary to assess treatment efficacy and detect recurrence 1
• Iron supplementation should be provided for all patients with GAVE-related anemia 1
• The choice between oral or IV iron depends on:
  • Severity of iron depletion 1
  • Patient tolerance to oral iron 1
  • No known malabsorptive defect exists in GAVE, so oral iron is typically sufficient 1

Treatment for Refractory GAVE

• For GAVE refractory to initial endoscopic therapy:
  • Consider switching from APC to EBL or RFA 4, 6
  • Combined approaches using submucosal injection of sclerosants (e.g., 1% Polidocanol) followed by APC may be effective in select cases 6
  • Surgical antrectomy with Billroth I anastomosis can be considered in cases refractory to all endoscopic approaches 6

Emerging Treatments

• Pharmacological therapy with azathioprine (100 mg daily) has shown promise in recent case reports, particularly in patients with suspected autoimmune etiology 2
• This approach may lead to complete mucosal healing and elimination of transfusion requirements in select patients 2

Important Clinical Considerations

• GAVE treatment should be distinguished from management of portal hypertensive gastropathy, which primarily focuses on reducing portal pressure through beta-blockers or TIPS 7
• Patients with GAVE often require multiple endoscopic sessions to achieve complete obliteration 4
• A high recurrence rate after endoscopic treatment should be anticipated, necessitating careful follow-up 4