Gastric Antral Vascular Ectasia

Gastric antral vascular ectasia (GAVE, watermelon stomach) is a vascular malformation of the gastric antrum characterised by dilated mucosal capillaries with fibromuscular hyperplasia, causing chronic gastrointestinal blood loss.

• Accounts for about 4% of non variceal upper gastrointestinal bleeding; affects older women (70% female, mean age 70).
• Associations: systemic sclerosis (up to 20% of patients, especially with anti RNA polymerase III antibodies), cirrhosis (30% of GAVE), chronic kidney disease, autoimmune disease (Raynaud, primary biliary cholangitis), bone marrow transplantation.
• Endoscopic patterns: classic (linear red stripes radiating from the pylorus along antral folds, like stripes of a watermelon), diffuse (honeycomb), and diffuse form more often in cirrhosis.
• Histology: dilated mucosal capillaries with fibrin thrombi, fibromuscular hyperplasia.
• Complications: iron deficiency anaemia, transfusion dependence, acute bleeding (uncommon).

• Chronic iron deficiency anaemia, occult gastrointestinal bleeding, melaena, haematemesis (less common), fatigue.
• Features of systemic sclerosis (skin thickening, Raynaud), cirrhosis (jaundice, ascites).
• Typically minimal other symptoms; weak epigastric discomfort.

• Upper endoscopy: red linear or punctate ectatic vessels in the antrum; distinguish from portal hypertensive gastropathy (mosaic pattern in the fundus and body).
• Biopsy: not usually required (risk of bleeding); histology confirms ectatic mucosal capillaries, fibrin thrombi, fibromuscular hyperplasia.
• Blood tests: full blood count, ferritin, iron studies, liver tests, renal function, autoimmune serology (ANA, anti RNA polymerase III, anti centromere).
• Evaluate small bowel with capsule endoscopy where anaemia persists.
• Assess for liver cirrhosis (elastography, imaging) and systemic sclerosis.

• Iron replacement (ferrous sulfate 200 mg daily, or IV iron: ferric carboxymaltose 15 mg/kg or iron sucrose) and transfusion when required.
• Endoscopic ablation is first line:
  • Argon plasma coagulation (power 30 to 60 W, flow 1 to 2 L/min), 2 to 4 sessions at 3 to 4 week intervals; success 70 to 90% in reducing transfusion.
  • Endoscopic band ligation (recurrence less than APC in some studies).
  • Radiofrequency ablation (HALO 90 or Barrx), cryotherapy, and Nd:YAG laser as alternatives.
• Drug therapy (limited evidence): tranexamic acid 500 mg to 1 g three times daily, octreotide, estrogen/progesterone, thalidomide 100 mg daily, corticosteroids, cyclophosphamide.
• Cirrhosis related GAVE: TIPS does not help GAVE (unlike portal hypertensive gastropathy); liver transplantation may not resolve GAVE.
• Surgical antrectomy for refractory transfusion dependent disease (curative, but morbidity).
• Treat underlying systemic sclerosis (immunosuppression for vascular disease).
• Follow up haemoglobin and ferritin every 3 months; repeat endoscopic treatment on recurrence.