What is Gastric Antral Vascular Ectasia (GAVE)?

What is Gastric Antral Vascular Ectasia (GAVE)?

GAVE is an uncommon vascular disorder of the gastric antrum that causes chronic gastrointestinal blood loss, presenting characteristically as parallel red stripes radiating from the pylorus (resembling watermelon stripes) or as diffuse red spots, leading to iron deficiency anemia and transfusion dependence. 1, 2

Endoscopic Appearance and Diagnosis

GAVE has two distinct endoscopic patterns that are pathognomonic:

• "Watermelon stomach": Red spots organized in stripes radiating from the pylorus along longitudinal antral folds 3
• "Honeycomb stomach": Red spots arranged in a diffuse pattern throughout the antrum 3
• Diagnosis is primarily endoscopic, with histology reserved for uncertain cases 3

Histopathologic Features

The characteristic microscopic findings include four key alterations (though not pathognomonic):

• Vascular ectasia of mucosal capillaries with dilated vessels and fibrin thrombi 1, 3
• Fibromuscular hyperplasia of the lamina propria (the defining histologic feature) 1, 2
• Focal thrombosis within ectatic vessels 3
• Fibrohyalinosis (homogeneous substance around ectatic capillaries) 3

Clinical Presentation

Chronic iron deficiency anemia requiring recurrent blood transfusions is the hallmark presentation, though acute bleeding can occur 2:

• Accounts for approximately 4% of non-variceal upper GI hemorrhage 3
• Patients typically present with melena and symptomatic severe anemia 4
• May require weekly blood transfusions in severe cases 4

Associated Conditions to Screen For

GAVE occurs in specific patient populations that require targeted screening:

Liver Disease

• Present in patients with cirrhosis, though critically, only 30% of GAVE patients have portal hypertension 1, 2
• Must be distinguished from portal hypertensive gastropathy (PHG), as these are separate entities requiring different treatments 1

Autoimmune/Connective Tissue Diseases

• Systemic sclerosis (scleroderma) is the most important association 1, 2
• Autoimmune disorders co-present in approximately 60% of GAVE patients, including Raynaud's phenomenon, sclerodactyly, Sjögren's syndrome, systemic lupus erythematosus, and primary biliary cirrhosis 3, 5

Renal Disease

• Chronic kidney disease and end-stage renal disease requiring dialysis 1, 2
• Recognized as a cause of chronic GI blood loss in dialysis patients 1

Other Associations

• Cardiac diseases, bone marrow transplantation, and chronic renal failure 3

Critical Distinction: GAVE vs. Portal Hypertensive Gastropathy

This distinction is essential because treatments differ fundamentally:

• GAVE can occur independently of portal hypertension and requires endoscopic ablation 1
• PHG primarily requires portal pressure reduction through beta-blockers or TIPS 6
• The two conditions can coexist in cirrhotic patients, requiring careful endoscopic differentiation 3

Common Pitfalls to Avoid

• Do not assume all gastric bleeding in cirrhotic patients is from varices or PHG—GAVE must be considered and distinguished endoscopically 1
• Do not treat GAVE with portal pressure reduction strategies alone—endoscopic therapy is required 6
• In patients with systemic sclerosis presenting with anemia, maintain high index of suspicion for GAVE even without overt bleeding 5