Correct answer: e.
Discussion
Patients with gastric antral vascular ectasia (GAVE), which is also known as watermelon stomach, usually present with iron deficiency anaemia. GAVE has been described in association with atrophic gastritis, achlorhydria/hypergastrinaemia, connective tissue diseases (such as systemic sclerosis), heart disease and chronic renal failure. One study suggested that a ‘punctate pattern’ was typical of GAVE in patients with cirrhosis, whilst a ‘striped type’ was more common in patients without cirrhosis.1
Portal hypertensive gastropathy (PHG) may also give rise to iron deficiency anaemia, but is probably a distinct condition as GAVE can develop in patients who have a normal portal pressure and the condition does not improve with TIPPS.2 Furthermore, PHG is more common in the gastric body and fundus and has the appearance of ‘snakeskin’.
The endoscopic appearance may be mild and easily confused with that of antral gastritis. Unfortunately, the classic histological findings of dilated and thrombosed capillaries in the lamina propria with fibromuscular hyperplasia may not be present in every case.3
Patients with bleeding from GAVE were previously treated with antrectomy. Now, the first-line treatment is endoscopic therapy. Octreotide and oestrogen-progesterone have also been used in small case series, but would now only be considered if endoscopic therapy fails. Argon plasma coagulation is probably the treatment of choice.4 When the ectasia radiates towards the pylorus, it is possible to withdraw the probe along the line of ectasia as argon is deployed. The photograph shows an example of the result at the end of an argon plasma coagulation treatment session. Recently thermal therapy with radiofrequency ablation has also been reported.
On occasion, I have been referred a patient with GAVE in whom endoscopic ablation has ‘failed’ to control the bleeding. However, with methodical endoscopic ablation therapy, perhaps taking 25 minutes per session and performing it twice a week for a couple of months, I have never failed to stabilise the blood loss. Indeed, a large series has reported efficacy approaching 100%.5
Subsequently, band ligation has been reported to require fewer treatment sessions than APC.6 More recently, radiofrequency ablation7 and cryotherapy8 have been reported as effective.
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