Journal of Visceral Surgery (2014) 151, 415—416
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL IMAGES
Gastric antral vascular ectasia unresponsive to endoscopic treatment requiring antrectomy C. Frasconi a, A. Charachon b, H. Perrin a,∗ a
Service de chirurgie viscérale et digestive, Centre Hospitalier Princesse-Grace, 1, avenue Pasteur, 98000, Monaco b Service d’hépato-gastro-entérologie, Centre Hospitalier Princesse-Grace, 1, avenue Pasteur, 98000, Monaco Available online 18 September 2014
KEYWORDS Gastric antral vascular ectasia; Gastrectomy; Argon plasma coagulation
∗
An 83-year-old female, taking steroid therapy for obstructive bronchopneumonia, was admitted in April 2013 for iron deficiency anemia. Vascular ectasias of the gastric antrum, undetected by CT scan, were found on upper endoscopy (Fig. 1); initial treatment was endoscopic coagulation using an Argon plasma laser. After three sessions, the patient sustained a pulmonary embolism that required therapeutic anticoagulation therapy resulting in renewed bleeding despite five further endoscopic coagulation sessions. The patient received 27 units of packed red cell transfusion between April and July 2013. Open laparotomy with antrectomy was therefore performed in August 2013 (Fig. 2). The pathology report confirmed the endoscopic and intra-operative findings (Fig. 3). Gastric antral vascular ectasias are responsible for 4% of upper gastrointestinal hemorrhage. One-third is associated with cirrhosis, and two-thirds with autoimmune disease. Their pathophysiology remains unknown. Diagnosis relies on endoscopy, which shows longitudinal rugal folds, composed of dilated mucosal capillaries coursing along the antrum [1], the so-called ‘‘watermelon stomach’’ described by Jabbari et al. in 1984 [2]. Histologic findings include mucosal venous dilatations with fibrin thrombi, fibrohyalin changes, and spindle cell proliferation in the lamina propria: these four criteria are part of a diagnostic score that is used in difficult, atypical cases [3]. Treatment is based on endoscopic Argon plasma coagulation, sometimes requiring multiple sessions [1]. Elastic band ligation and radiofrequency coagulation are currently under evaluation. Somatostatin analogues can also be used [4]. In the present case, pulmonary embolism was either idiopathic or the initial symptom of an autoimmune disease, while the need for anticoagulation accounted for the failure of endoscopic hemostasis. Antrectomy is indicated only when endoscopic treatment has failed. Recurrence in other parts of the stomach after antrectomy has never been described although vascular ectasias have also been described in the cardia, the duodenum or jejunum. Vascular ectasias located in the gastric corpus or fundus are suggestive of portal hypertension in the patient with cirrhosis.
Corresponding author. E-mail address: [email protected] (H. Perrin).
http://dx.doi.org/10.1016/j.jviscsurg.2014.07.003 1878-7886/© 2014 Elsevier Masson SAS. All rights reserved.
416
Figure 1. Endoscopic view: longitudinal gastric rugae composed of dilated mucosal capillaries, giving the ‘‘watermelon stomach’’ appearance.
C. Frasconi et al.
Figure 3. Microscopic view of the antral mucosa. Presence of two of three histological criteria for the diagnostic score described by Payen et al. [3] in 1995: a. Mucosal vascular ectasia. b. Fibrin thombus. c. Spindle cell proliferation. On this slide, submucosal fibrohyaline change is not present.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
Acknowledgements We would like to thank Doctors F. Dupré and J.F. Roussel from the Princesse Grace Hospital Pathology department for their diagnostic contribution and images.
References
Figure 2. Operative specimen: a. Longitudinal dilated mucosal vascular ectasias of the antrum. b. Height of antral ectasia.
[1] Sellinger CP, Ang YS. Gastric antral vascular ectasia (GAVE): an update on clinical presentation, pathophysiology and treatment. Digestion 2008;77:131—7. [2] Jabbari M, Cherry R, Lough JO, Daly DS, Kinnear DG, Goresky CA. Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology 1984;87(5):1965—70. [3] Payen JL, Calès P, Voigt JJ, et al. Severe portal hypertensive gastropathy and antral vascular ectasia are distinct entities in patients with cirrhosis. Gastroenterology 1995;108(1):138—44. [4] Fuccio L, Mussetto A, Laterza L, Eusebi LH, Bazzoli F. Diagnosis and management of gastric antral vascular ectasia. World J Gastrointest Endosc 2013;5(1):6—13.
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL IMAGES
Gastric antral vascular ectasia unresponsive to endoscopic treatment requiring antrectomy C. Frasconi a, A. Charachon b, H. Perrin a,∗ a
Service de chirurgie viscérale et digestive, Centre Hospitalier Princesse-Grace, 1, avenue Pasteur, 98000, Monaco b Service d’hépato-gastro-entérologie, Centre Hospitalier Princesse-Grace, 1, avenue Pasteur, 98000, Monaco Available online 18 September 2014
KEYWORDS Gastric antral vascular ectasia; Gastrectomy; Argon plasma coagulation
∗
An 83-year-old female, taking steroid therapy for obstructive bronchopneumonia, was admitted in April 2013 for iron deficiency anemia. Vascular ectasias of the gastric antrum, undetected by CT scan, were found on upper endoscopy (Fig. 1); initial treatment was endoscopic coagulation using an Argon plasma laser. After three sessions, the patient sustained a pulmonary embolism that required therapeutic anticoagulation therapy resulting in renewed bleeding despite five further endoscopic coagulation sessions. The patient received 27 units of packed red cell transfusion between April and July 2013. Open laparotomy with antrectomy was therefore performed in August 2013 (Fig. 2). The pathology report confirmed the endoscopic and intra-operative findings (Fig. 3). Gastric antral vascular ectasias are responsible for 4% of upper gastrointestinal hemorrhage. One-third is associated with cirrhosis, and two-thirds with autoimmune disease. Their pathophysiology remains unknown. Diagnosis relies on endoscopy, which shows longitudinal rugal folds, composed of dilated mucosal capillaries coursing along the antrum [1], the so-called ‘‘watermelon stomach’’ described by Jabbari et al. in 1984 [2]. Histologic findings include mucosal venous dilatations with fibrin thrombi, fibrohyalin changes, and spindle cell proliferation in the lamina propria: these four criteria are part of a diagnostic score that is used in difficult, atypical cases [3]. Treatment is based on endoscopic Argon plasma coagulation, sometimes requiring multiple sessions [1]. Elastic band ligation and radiofrequency coagulation are currently under evaluation. Somatostatin analogues can also be used [4]. In the present case, pulmonary embolism was either idiopathic or the initial symptom of an autoimmune disease, while the need for anticoagulation accounted for the failure of endoscopic hemostasis. Antrectomy is indicated only when endoscopic treatment has failed. Recurrence in other parts of the stomach after antrectomy has never been described although vascular ectasias have also been described in the cardia, the duodenum or jejunum. Vascular ectasias located in the gastric corpus or fundus are suggestive of portal hypertension in the patient with cirrhosis.
Corresponding author. E-mail address: [email protected] (H. Perrin).
http://dx.doi.org/10.1016/j.jviscsurg.2014.07.003 1878-7886/© 2014 Elsevier Masson SAS. All rights reserved.
416
Figure 1. Endoscopic view: longitudinal gastric rugae composed of dilated mucosal capillaries, giving the ‘‘watermelon stomach’’ appearance.
C. Frasconi et al.
Figure 3. Microscopic view of the antral mucosa. Presence of two of three histological criteria for the diagnostic score described by Payen et al. [3] in 1995: a. Mucosal vascular ectasia. b. Fibrin thombus. c. Spindle cell proliferation. On this slide, submucosal fibrohyaline change is not present.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
Acknowledgements We would like to thank Doctors F. Dupré and J.F. Roussel from the Princesse Grace Hospital Pathology department for their diagnostic contribution and images.
References
Figure 2. Operative specimen: a. Longitudinal dilated mucosal vascular ectasias of the antrum. b. Height of antral ectasia.
[1] Sellinger CP, Ang YS. Gastric antral vascular ectasia (GAVE): an update on clinical presentation, pathophysiology and treatment. Digestion 2008;77:131—7. [2] Jabbari M, Cherry R, Lough JO, Daly DS, Kinnear DG, Goresky CA. Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology 1984;87(5):1965—70. [3] Payen JL, Calès P, Voigt JJ, et al. Severe portal hypertensive gastropathy and antral vascular ectasia are distinct entities in patients with cirrhosis. Gastroenterology 1995;108(1):138—44. [4] Fuccio L, Mussetto A, Laterza L, Eusebi LH, Bazzoli F. Diagnosis and management of gastric antral vascular ectasia. World J Gastrointest Endosc 2013;5(1):6—13.
