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

Management of Gastric Antral Vascular Ectasia (GAVE)

Endoscopic band ligation (EBL) is the most effective first-line endoscopic treatment for GAVE, requiring fewer sessions than thermal methods and achieving superior outcomes in transfusion reduction and hemoglobin improvement. 1

Initial Endoscopic Approach

Endoscopic Band Ligation (Preferred)

• EBL demonstrates superior efficacy compared to thermal ablation methods, with a mean reduction of 2.30 fewer transfusions and 0.59 g/dL greater hemoglobin improvement 1
• EBL requires significantly fewer treatment sessions to achieve obliteration (mean 2.63 sessions vs 3.83 sessions for thermal methods) 1
• Clinical studies show bleeding cessation rates of 67% with EBL versus only 23% with endoscopic thermal therapy (ETT), with statistical significance (P = 0.04) 2
• EBL achieves greater reduction in transfusion requirements (-12.7 vs -5.2 units, P = 0.02) and hospitalizations (-2.6 vs -0.5 admissions, P = 0.02) compared to thermal methods 2
• Adverse events with EBL are rare and mild, including nausea, vomiting, esophageal or abdominal pain, and occasional hyperplastic polyps 3

Argon Plasma Coagulation (Alternative)

• APC has traditionally been the most commonly used endoscopic treatment, with success rates ranging from 40-100% 3
• Major limitation: APC requires multiple treatment sessions with high recurrence rates of 10-78.9% 3
• APC-related adverse events include hyperplastic gastric polyps, sepsis, and occasionally Mallory-Weiss syndrome 3

Management of Refractory GAVE

Radiofrequency Ablation (Second-Line)

• RFA is highly effective for GAVE refractory to APC, with success rates of 90-100% and transfusion independence achieved in 86% of patients at 6 months 4
• RFA increases mean hemoglobin from 7.8 to 10.2 g/dL in responders 4
• Recurrence rates with RFA range from 21.4-33.3%, which is lower than APC but higher than EBL 3
• Important caveat: RFA is classified as high-risk for hemorrhage in patients on anticoagulants or P2Y12 receptor antagonists 5
• RFA-related adverse events include hyperplastic polyps and a 10% ulceration rate that may necessitate discontinuation 5

Adjunctive Medical Management

Iron Supplementation

• All patients with GAVE-related anemia require iron supplementation 1
• Choose between oral or IV iron based on severity of iron depletion, patient tolerance to oral formulations, and absence of malabsorptive defects 1

Critical Diagnostic Distinction

Differentiate GAVE from Portal Hypertensive Gastropathy

• GAVE must be distinguished from portal hypertensive gastropathy (PHG) as these are separate entities requiring different treatments 6
• Approximately 30% of GAVE patients have portal hypertension, but GAVE can occur independently of portal hypertension 6
• PHG management focuses on reducing portal pressure through beta-blockers or TIPS, whereas GAVE requires endoscopic ablation 1
• GAVE pathophysiology involves dilated vessels with fibrin thrombi and fibromuscular hyperplasia of the lamina propria, distinct from PHG 6

Follow-Up Protocol

Surveillance Strategy

• Regular follow-up endoscopy is necessary to assess treatment efficacy and detect recurrence 1
• High recurrence rates after endoscopic treatment (8.3-48.1% for EBL, up to 78.9% for APC) mandate vigilant endoscopic surveillance 3

Common Pitfalls to Avoid

• Do not confuse GAVE with PHG: treating GAVE with portal pressure reduction alone will fail 1, 6
• Do not rely solely on APC as definitive therapy: its high recurrence rate and need for multiple sessions make it suboptimal compared to EBL 1, 3
• Exercise caution with RFA in anticoagulated patients: consider temporary discontinuation of anticoagulation given the high-risk classification 5
• Do not place more than six bands per EBL session: this may help reduce post-banding ulcer hemorrhage risk 5