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Stepwise endoscopic eradication of refractory nodular gastric antral vascular ectasia by use of detachable snare and band ligation

Open AccessPublished:December 15, 2016DOI:https://doi.org/10.1016/j.vgie.2016.11.004
      Gastric antral vascular ectasia (GAVE) is characterized by ectatic mucosal vessels with fibrin thrombi often localized to the gastric antrum. It is an uncommon cause of chronic GI blood loss associated with cirrhosis, autoimmune connective tissue disorders, bone marrow transplantation, and chronic kidney disease. Although GAVE often presents with characteristic flat, striped erythema radiating proximally from the pylorus (the so-called watermelon stomach), it can take on a nodular or polypoid appearance. Nodular GAVE can be mistaken endoscopically for gastric polyps, which may require biopsy and histologic evaluation for confirmation. In patients presenting with acute or chronic GI blood loss with endoscopic findings of GAVE, endoscopic therapy is warranted. A broad literature base describes the use of mucosal ablative therapies, including argon plasma coagulation and, to a lesser degree, radiofrequency ablation and cryotherapy with the use of liquid nitrogen for the eradication of GAVE. Whatever modality is pursued, serial endoscopic treatments are often required to achieve complete eradication. Endoscopic band ligation, a purely mechanical procedure, has also been reported as an effective salvage therapy for GAVE that is refractory to the aforementioned approaches. We present the case of a 58-year-old man with alcoholic cirrhosis listed for liver transplantation who presented with chronic GI blood loss and transfusion-dependent anemia secondary to bleeding nodular GAVE (Fig. 1A). He had experienced ongoing blood loss despite multiple treatments with argon plasma coagulation at another hospital. A mechanical approach was undertaken with sequential endoscopic band ligation, with the use of a detachable snare ligature for the larger lesions at 2-month intervals (Video 1, available online at www.VideoGIE.org; Figs. 1B-D). This led to successful eradication and resolution of the patient’s anemia and GI blood loss after multiple treatment sessions (Figs. 1E-G).
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      Figure 1A, Endoscopic image from the index endoscopy, demonstrating multiple erythematous friable antral polypoid and nodular lesions ranging in size from 3 to 25 mm in a radial pattern extending from the pylorus, representing nodular gastric antral vascular ectasia (GAVE). B, Endoscopic image from the second endoscopy, demonstrating detachable snare ligature deployment over a large area of nodular GAVE with tissue ischemia. C, Endoscopic image from the second endoscopy, after detachable snare ligature and endoscopic band deployment over a large area of nodular GAVE. D, Endoscopic image from the second endoscopy, after detachable snare ligature and endoscopic band deployment over areas of nodular GAVE with tissue ischemia. E, Endoscopic image from the fourth endoscopy, demonstrating significant improvement in the extent of nodular GAVE. F, Endoscopic images from the first through the fourth endoscopies, demonstrating stepwise improvement in nodular GAVE. G, Graphic depiction of patient’s hemoglobin level, blood transfusion requirement, and endoscopic therapies over 8-month period before and after initiation of endoscopic ligation therapy of GAVE. GAVE, gastric antral vascular ectasia; RBC, red blood cells.
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      Figure 1A, Endoscopic image from the index endoscopy, demonstrating multiple erythematous friable antral polypoid and nodular lesions ranging in size from 3 to 25 mm in a radial pattern extending from the pylorus, representing nodular gastric antral vascular ectasia (GAVE). B, Endoscopic image from the second endoscopy, demonstrating detachable snare ligature deployment over a large area of nodular GAVE with tissue ischemia. C, Endoscopic image from the second endoscopy, after detachable snare ligature and endoscopic band deployment over a large area of nodular GAVE. D, Endoscopic image from the second endoscopy, after detachable snare ligature and endoscopic band deployment over areas of nodular GAVE with tissue ischemia. E, Endoscopic image from the fourth endoscopy, demonstrating significant improvement in the extent of nodular GAVE. F, Endoscopic images from the first through the fourth endoscopies, demonstrating stepwise improvement in nodular GAVE. G, Graphic depiction of patient’s hemoglobin level, blood transfusion requirement, and endoscopic therapies over 8-month period before and after initiation of endoscopic ligation therapy of GAVE. GAVE, gastric antral vascular ectasia; RBC, red blood cells.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

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