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Srinadh Komanduri, MD
Director, Interventional Endoscopy
Division of Gastroenterology and Hepatology
Northwestern University Feinberg School of Medicine
Chicago, Illinois

Gastric antral vascular ectasia (GAVE) is a cause of upper GI bleeding and chronic iron-deficiency anemia, often resulting in long-term blood transfusion dependence. In a single study of patients undergoing orthotopic liver transplantation, 2.3% of patients were found to have an endoscopic diagnosis of GAVE. In this population, it is important to differentiate GAVE from portal hypertensive gastropathy because portal hypertensive gastropathy will respond to measures that reduce portal pressures, whereas GAVE will not. Previously attempted systemic interventions for GAVE, including corticosteroids, octreotide, and estrogen/progesterone combinations, have neither decreased the need for transfusions nor resolved the abnormal gastric mucosa found in GAVE patients. Surgical options, such as antrectomy, are curative but accompanied by high morbidity and mortality. Current standard of care for the treatment of GAVE uses endoscopic thermoablation techniques to eradicate the ectatic vessels that lead to blood loss. Endoscopic options for therapy have included Nd:YAG laser ablation, heater probe, cryotherapy, and argon plasma coagulation (APC). APC has become the most common endoscopic therapy for the treatment of GAVE because of its relative ease of use and safety compared with other endoscopic treatments. However, issues related to gas insufflation, incomplete ablation, and recurrence of bleeding remain detractors to this therapy.1

Radiofrequency ablation (RFA) is an endoscopic ablation technique used for treatment of Barrett’s esophagus. This system also has FDA clearance for treatment of GAVE.1 A recent study of 21 transfusion-dependent patients with GAVE refractory to APC demonstrated clinical success with no transfusion requirements for 86% of patients after therapy with RFA.1 A mean increase in hemoglobin from 7.8 to 10.2 g/dL was noted with no significant adverse events.1

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Endoscopic images of a patient with gastric antral vascular ectasia before and immediately following radiofrequency ablation, and at 3-month follow-up (left to right).

Case Presentation

A 65-year-old man with hepatitis C cirrhosis (Model for End-Stage Liver Disease score, 15) was admitted with symptomatic anemia and hemoglobin of 6.2 g/dL. The patient had 3 treatments of APC for GAVE in the past 2 months with no response. He required blood transfusion every 2 weeks. He had no overt GI bleed and previous endoscopies had not demonstrated significant stigmata of portal hypertension. The patient was afebrile and hemodynamically stable with a pulse of 72 bpm and blood pressure of 124/81 mm Hg. The patient had no other significant medical history and was on a nonselective β-blocker. On physical examination, the patient had multiple spider angiomata, some conjunctival pallor, and palmar erythema. Examination findings were otherwise normal. The patient received 4 units of blood and subsequently underwent endoscopy, which showed significant GAVE. The patient was treated with RFA. He tolerated the procedure well and required only 2 units of blood in the next 3 months. Follow-up endoscopy at 3 months demonstrated 75% treatment response with minimal persisting GAVE. A final RFA treatment was performed. The patient remained transfusion independent out to 12 months. He is currently awaiting liver transplantation.

Discussion

GAVE continues to be a significant source of obscure GI bleeding and anemia.1,2 It is common in patients with liver disease2 and can be debilitating. RFA is a safe and effective alternative for treatment of GAVE when standard therapy with APC is ineffective.1

References

  1. Reprinted from Gastrointestinal Endoscopy, vol. 78(4), Tim McGorisk, MD, Kumar Krishnan, MD, Laurie Keefer, PhD, Srinadh Komanduri, MD, MS, Radiofrequency ablation for refractory gastric antral vascular ectasia (with video)., 584-588, Copyright 2013, with permission from Elsevier.
  2. Qureshi K, Al-Osaimi AM. Approach to the management of portal hypertensive gastropathy and gastric antral vascular ectasia. Gastroenterol Clin North Am. 2014;43(4):835-847.