What are the clinical manifestations and management options for Gastric Antral Vascular Ectasia (GAVE)?

Clinical Presentation of GAVE

GAVE (Gastric Antral Vascular Ectasia) presents as chronic gastrointestinal blood loss leading to iron deficiency anemia and transfusion dependence, though acute bleeding can occur. 1

Key Clinical Manifestations

• Chronic iron deficiency anemia is the most common presentation, often requiring recurrent blood transfusions 1, 2
• Occult gastrointestinal bleeding manifesting as progressive anemia rather than overt hematemesis or melena 2
• Acute upper GI hemorrhage can occur but is less common than chronic blood loss 2, 3

Endoscopic Appearance

• Red spots without background mosaic pattern, typically localized to the gastric antrum 3
• Linear distribution of vascular ectasias creating the characteristic "watermelon stomach" appearance 3
• Must be distinguished from portal hypertensive gastropathy (PHG), which shows a mosaic pattern with red signs and more proximal distribution 4, 3

Associated Conditions to Screen For

• Cirrhosis and liver disease (though only 30% of GAVE patients have portal hypertension) 4
• Systemic sclerosis (scleroderma) and other autoimmune connective tissue diseases 4, 2
• Chronic kidney disease and end-stage renal disease requiring dialysis 4, 2
• Bone marrow transplantation history 2

Pathophysiology

• Dilated vessels with fibrin thrombi in the gastric mucosa 4
• Fibromuscular hyperplasia of the lamina propria is the characteristic histologic feature 4

Management Algorithm for GAVE

Step 1: Iron Replacement (All Patients)

• Initiate iron supplementation immediately in all patients with GAVE-related iron deficiency anemia 1
• Oral iron is appropriate initially as there is no malabsorptive defect in GAVE 1
• Switch to IV iron if oral iron is not tolerated, ferritin levels fail to improve, or profound anemia exists 1

Step 2: Endoscopic Therapy (First-Line Definitive Treatment)

Endoscopic band ligation (EBL) is superior to thermal ablation methods and should be the preferred first-line endoscopic approach. 1

Endoscopic Band Ligation (Preferred)

• Requires fewer treatment sessions (mean 2.63 vs 3.83 sessions compared to thermal methods) 1
• Greater reduction in transfusion requirements (mean difference -2.30 transfusions; 95% CI, -4.11 to -2.48) 1
• More pronounced hemoglobin improvement (0.59 g/dL greater increase; 95% CI, 0.17–1.00) 1
• Favorable safety profile with high endoscopic success rates 1

Thermal Ablation Methods (Alternative)

• Argon plasma coagulation (APC) is the most established thermal method with 40-100% endoscopic success rate 5, 6
• Radiofrequency ablation (RFA) shows 90-100% success rates but is technically challenging 5
• APC requires multiple sessions (typically 3-4) with recurrence rates of 10-78.9% 5
• Consider thermal methods when EBL is not feasible or available [1, @12@]

Important Caveat

• GAVE does not respond to portal pressure reduction, so beta-blockers and TIPS are ineffective and should not be used 2, 3

Step 3: Refractory Cases

Medical Therapy (Compassionate Use Only)

Reserve pharmacologic therapy for patients who fail both iron replacement and endoscopic therapy. 1

• Thalidomide has the strongest evidence among medical therapies, showing dose-dependent reduction in rebleeding 1, 7
• Significant adverse effects include peripheral neuropathy, constipation, and bowel perforation 1
• Should only be prescribed by providers experienced with thalidomide due to toxicity profile 1
• Somatostatin analogues (octreotide preferred over lanreotide) may reduce transfusion requirements but evidence is not robust 1

Surgical Intervention

• Antrectomy should be reserved for truly unresponsive cases as it carries high mortality 2
• Consider only after all endoscopic and medical options exhausted 2

Critical Distinction: GAVE vs Portal Hypertensive Gastropathy

This distinction is essential because treatments differ completely:

• GAVE does not respond to beta-blockers or TIPS (which are effective for PHG) 2, 3
• PHG shows mosaic pattern with proximal distribution; GAVE shows red spots in antrum without mosaic pattern 3
• GAVE can occur independently of portal hypertension in 70% of cases 4

Follow-Up Strategy

• High recurrence rates (8.3-78.9% depending on modality) necessitate regular endoscopic surveillance 5
• Monitor hemoglobin and iron stores to detect recurrent bleeding early 1
• Repeat endoscopic therapy as needed for recurrent lesions 5