Aamir Ghafoor Khan
Department of Gastroenterology and Hepatology Ayub Medical College, Abbottabad. Pakistan.
In this paper the condition Gastric Vascular Ectasia (GAVE) is reviewed and two patients of gastric vascular antral ectasia are reported (GAVE). It is suggested that the diagnostic possibility of Gastric antral vascular ectasia should be considered in any elderly patient, more so in females, with persistent unexplained Iron deficiency anaemia.
Since the description of a case of gastritis with veno-capillary ectasia as a source of massive haemorrhage by Rider et al in 19531 many cases have now been recognised. In 1984 Jabari et al2 further defined this condition as ‘watermelon stomach’ based on its endoscopic appearance. This condition appears to be a somewhat rare entity. This is report of two cases of this disease, both encountered at Hairmyres Hospital, Glasgow over a period of five years during which 2500 endoscopies were done.
A 64 years old lady was admitted for an episode of melena, which had been preceded by one month of upper abdominal pain, against a long background of dyspepsia. On examination she was found to be anaemic.
Investigations showed iron defici-ency anaemia and haemoglobin (Hb) 10.5 g/dl. Stools were positive for occult blood. Barium meal and follow through showed persistent narrowing and reduced distensibiltity in region of gastric antrum. The muscosal pattern however appeared intact. Upper G.I. endoscopy showed very striking red streaked appearance of antrum with multiple small raised red lesions. Biospy from the lesion showed small collection of telangiectatatic capillaries lined by prominent endothelial cells and one vessel contained thrombus. Biospy from gastric area showed mild to moderate active chronic gastritis. While she was under observation her stools continued to be positive for occult blood. Her Hb fell to 9.2g/dl. She was transfused. Repeat endoscopy showed essentially similar features. She was subjected to Antrectomy and Billroth I anastomosis. Gross biopsy specimen of pyloric antrum showed prominence of rugae with red streaks over the tips of gastric folds. Small pectial foci were seen in mucosa. There were small groups of blood vessels in submucosa. Histology showed several small groups of superficially located dilated capillaries, some of which contained fibrin thrombus. There was focal fibro-muscular proliferation in the lamina propria. The submucosa was oedmatous. There were groups of ectatic venous channels. Her haemoglobin remained stable at around 14g/dl after surgery during two years follow up.
A 73 years old woman was admitted for weight loss, malaise, dyspnoea and ankle swelling. On examination she was anaemic. She also had atrial fibrillation and signs of early congestive cardiac failure.
Her investigation showed iron deficiency anaemia due to chronic blood loss and Hb 7.1g/dl. Stools were positive for occult blood. ESR was high. Immunoglobulins showed very high IgM 8.47g/l (91%mean normal adult value). Liver Function Tests showed mild elevation of ALT (45.2). Barium meal and enema were normal.
She was treated for congestive cardiac failure. She was transfused. As her symptoms remained unchanged with persistently low Hb, an upper GI endoscopy was done to exclude primary gastric lesion.
The gastric antrum was grossly abnormal with typical appearance of watermelon stomach (Figure1).
Figure 1: An upper endoscopy reveals longitudinal erythematous stripes resembling stripes of a water melon
Biopsy from the lesion showed small group of telangatatic vessels some of which contained thrombus in lamina propria. In addition fibromuscular element was present in mucosa.
She was advised surgery, which she refused. She is still being followed up and remains rather tired and her last checked Hb was 9.4g/dl
In an elderly patient, especially in females persistent iron deficiency anaemia with hypochlorydria or achlorhydria should warrant the diagnostic possibility of gastric vascular ectasia. The mean age of presentation is 69.1 years (range 42-89 yrs). Patient most commonly present with chronic occult blood loss or recurrent acute haemorrhage.3,4 The common clinical presentations are iron deficiency anaemia (88%), Faecal Occult Blood (FOB) positive (42%), Melena (15%), hematemesis (3%) and rarely hematochezia (1%).5 The occult bleeding is transfusion dependent with a mean of 10 units over a 12-month period.
The aetiology of this condition remains unknown; one theory being that water melon stomach is caused by recurrent episodes of antral mucosal prolapse into pylorus that leads to mucosal trauma and ischemia.
Other conditions are associated with this condition. In one series3 the most common associated disorders were Raynaud’s phenomenon (31%) and sclerodactely (18%). Other associated conditions include hypothyroidism, primary biliary cirrhosis, diabetes mellitus and autoimmune liver disease.3-7
The diagnostic endoscopic findings are both uniform and remarkably characteristic, these include longitudinal rugal folds transforming the antrum and converging on pylorus, each containing a visible convoluted column of vessels, the aggregate resembling the stripes of water melon.2
Other features include gastritis with evidence of mucosal prolapse. Conventional radiology is often non-specific. Both gross appearance of resected antrum and microscopic picture is characteristic. The resected specimen shows thickened mucosa with torturous submucosal venous channels. Microscopic picture may show dilatation of muscoal capillaries with focal thrombosis and fibromuscular hyperplasia of lamina propria1,2,
The therapeutic options are numerous for this condition and need to be individualised. Improvement of anaemia with out further iron supplementation following surgery in patients including one of our own case (Case1) suggest that the most appropriate treatment for this condition is antrectomy with Billroth I anastomosis, but their is mortality of 7.4%8 associated with this operation.
Endoscopic therapy has been shown to be effective with a minimal mortality. Endoscopic therapy, including the NDYAG laser, argon laser, heater probe, bipolar therapy have been effective as a treatment. The number of endoscopic sessions needed varied between 3-4 sessions over period of 4-12 months.3,6,7,9-11
Pharmacological agents like prednisone,2,12 prednisolone,13,14 estrogen-progesterone preparations13 have been used with various success rates. Octreotide was not shown to be effective.15
In conclusion, Watermelon stomach is an increasingly recognisable cause of persistent acute or occult gastrointestinal bleeding, especially in elderly women. Usually presenting as severe iron deficiency anaemia and occult or overt gastrointestinal blood loss. Diagnosis is endoscopic, with characteristic appearance of watermelon like linear stripes in antrum. Histology is rarely needed to confirm the diagnosis. The important thing is to recognise the characteristic lesion and carry out appropriate endoscopic procedure, leading to healing of the lesion with significant improvement in the anaemia and a reduction in the need for blood transfusions.
1. Rider JA, Koltz AP, Kirsner JB. Gastritis with veno-capillary ectasia as source of massive gastric hemorrhage. Gastroenterology 1953:24;118-23.
2. Jabbari M, Cherry R, Lough JO, Daly DS, Kinnear DG, Goresky CA. Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology 1984; 87:1165-70.
3. Gostout CJ, Viggiano TR, Ahlquist DA, Wang KK, Larson MV, Balm R. The clinical and endoscopic spectrum of the watermelon stomach. J Clinical Gastroenterol 1992; 15:256-63.
4. Merrett MN, Machet D, Ring J, Desmond PV, Martin CJ. Watermelon stomach: an unusual cause of chronic gastrointestinal blood loss. Aust N Z J Surg 1991;61:393-96.
5. Gretz JE, Achem SR. The watermelon stomach: clinical presentation, diagnosis, and treatment. Am J Gastroenterol 1998; 93:890-5.
6. Gostout CJ, Ahlquist DA, Radford CM, Viggiano TR, Bowyer BA, Balm RK. Endoscopic laser therapy for watermelon stomach. Gastroenterology 1989;96:1462-5.
7. Tsai HH, Smith J, Danesh BJ. Successful control of bleeding from gastric antral vascular ectasia (watermelon stomach) by laser photocoagulation. Gut 1991; 32:93-4.
8. Borsch G. Diffuse gastric antral vascular ectasia: the "watermelon stomach" revisited. Am J Gastroenterol 1987; 82:1333-4.
9. Bjorkman DJ, Buchi KN. Endoscopic laser therapy of the watermelon stomach. Lasers Surg Med 1992; 12:478-81.
10. Frager JD, Brandt LJ, Frank MS, Morecki R. Treatment of a patient with watermelon stomach using transendoscopic laser photocoagulation. Gastrointest Endosc 1988; 34:134-7.
11. Watson M, Hally RJ, McCue PA, Varga J, Jimenez SA. Gastric antral vascular ectasia (watermelon stomach) in patients with systemic sclerosis. Arthritis Rheum 1996; 39:341-6.
12. Kruger R, Ryan ME, Dickson KB, Nunez JF. Diffuse vascular ectasia of the gastric antrum. Am J Gastroenterol 1987; 82:421-6.
13. Moss SF, Ghosh P, Thomas DM, Jackson JE, Calam J. Gastric antral vascular ectasia: maintenance treatment with estrogen-progesterone. Gut 1992; 33:715-7.
14. Rawlinson WD, Barr GD, Lin BP. Antral vascular ectasia – the "watermelon" stomach. Med J Aust 1986;144:709-11.
15. Barbara G, De GR, Salvioli B, Stanghellini V, Corinaldesi R. Unsuccessful octreotide treatment of the watermelon stomach. J Clin Gastroenterol 1998; 26:345-6
Address For Correspondence:
Dr Aamir Ghafoor Khan, Assistant Professor, Department of Gastroenterology and Hepatology, Ayub Medical College, Abbottabad.