The watermelon stomach: Long-term outcome in patients treated with ND:YAG laser therapy

doi:10.1016/S0016-5107(94)70258-6

Gastrointestinal Endoscopy

Volume 40, Issue 5, September–October 1994, Pages 584-587

https://doi.org/10.1016/S0016-5107(94)70258-6 Get rights and content

Abstract

Watermelon stomach is an unusual cause of gastrointestinal bleeding and iron deficiency anemia. Its etiology is unknown, but it has been reported to be associated with a variety of diseases, including autoimmune disorders and cirrhosis. We report on the long-term outcome of 15 patients (13 women, 2 men) treated with neodymium-yttrium-aluminum-garnet (Nd:YAG) laser therapy. The mean age of patients at presentation was 71.6 years (range, 59 to 85 years). Fourteen patients were transfusion-dependent, requiring an average of 9.6 units of blood in the 12 months preceding diagnosis and treatment. Associated diseases included scleroderma (3 patients), mixed connective tissue disease (1 patient), history of cancer (3 patients), cryptogenic cirrhosis (3 patients), and chronic renal failure (3 patients). In 7 of 9 patients who had an antinuclear antibody test, an elevated titer greater than 1:160 in a speckled pattern was noted. Nd:YAG laser coagulation therapy was administered to all patients without complications and was successful in reducing bleeding in every case. Five patients died during the course of follow-up without signs of recurrent gastrointestinal bleeding. The remaining 10 patients have had both endoscopic and hematologic improvement during a mean follow-up period of 4.4 years from the time of initial diagnosis (range, 2 to 8 years). The 10 survivors are no longer transfusion-dependent and have stable hematocrits. (Gastrointest Endosc 1994;40:584-7.)

Section snippets

Patients

Fifteen patients, referred for treatment of anemia and vascular ectasia of the stomach, met the criteria for watermelon stomach as determined by a classic endoscopic appearance and absence of other sources of bleeding. Pretreatment studies included colonoscopy, barium enema, UGI series with and without small bowel follow-through, enteroclysis, and CT of the abdomen. Before the referral for treatment of continued bleeding, two patients had undergone multipolar electrocoagulation therapy (BICAP,

Patient characteristics

Patient characteristics are summarized in Table 1. Of the 15 patients treated, 13 were women and 2 were men. The mean age at presentation was 71.6 years, and presenting symptoms included melena, angina, and shortness of breath. All patients were anemic at the time of presentation. Fourteen of the 15 patients were transfusion-dependent, requiring an average of 9.6 units of blood in the 12 months before the initiation of therapy. The duration of anemia had ranged from 2 months to 7 years. All

DISCUSSION

This retrospective study of laser photocoagulation treatment of an unusual cause of gastrointestinal blood loss and associated anemia supports and extends the findings of others4, 10, 12, 14, 15 regarding the utility and safety of laser therapy for this disease process.

Since watermelon stomach was first described in 3 patients in 1984,¹ various types of therapy have been attempted. Surgery with antrectomy and Billroth I anastomosis has been tried¹; prednisone therapy has been shown to bring

Acknowledgements

The authors thank Susan Huntzinger for her expert assistance.

References (18)

M Jabbari et al.
Gastric antral vascular ectasia: the watermelon stomach
Gastroenterology
(1984)
E Quintero et al.
Gastric mucosal vascular ectasia causing bleeding in cirrhosis. A distinct entity associated with hypergastrinemia and low serum levels of pepsinogen I
Gastroenterology
(1987)
FI Lee et al.
Diffuse antral vascular ectasia
Gastrointest Endosc
(1984)
CJ Gostout et al.
Endoscopic laser therapy for watermelon stomach
Gastroenterology
(1989)
JL Petrini et al.
Heat probe treatment for antral vascular ectasia
Gastrointest Endosc
(1989)
KF Binmoeller et al.
Bipolar electrocoagulation for watermelon stomach
Gastrointest Endosc
(1990)
JD Frager et al.
Treatment of a patient with watermelon stomach using transendoscopic laser photocoagulation
Gastrointest Endosc
(1988)
TD Lewis et al.
Arteriovenous malformation of the stomach: radiologic and endoscopic features
American Journal of Digestive Diseases
(1978)
T Arendt et al.
Diffuse gastric antral vascular ectasia: cause of chronic gastrointestinal blood loss
Endoscopy
(1987)

There are more references available in the full text version of this article.

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Mixed connective tissue disease
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There are isolated reports of MCTD with autoimmune hepatitis [74–76], primary biliary cirrhosis [77], portal hypertension [78], and protein-losing enteropathy [79,80]; however, overall, it appears that GI (gastrointestinal) complications other than dysmotility of the esophagus are infrequent in MCTD. Interestingly, angiodysplasia of the gastric antrum, a recognized complication of SSc [81], has only been reported in a single MCTD patient [82]. There are no recent data on the hematological alterations in MCTD, but the older studies indicate that anemia and leucopenia are common during the disease course whereas thrombocytopenia is reported to be infrequent [10,13,17,53].
The concept of mixed connective tissue disease (MCTD) as a separate connective tissue disease (CTD) has persisted for more than four decades. High titers of antibodies targeting the U1 small nuclear ribonucleoprotein particle (U1 snRNP) in peripheral blood are a sine qua non for the diagnosis of MCTD, in addition to distinct clinical features including Raynaud's phenomenon (RP), “puffy hands,” arthritis, myositis, pleuritis, pericarditis, interstitial lung disease (ILD), and pulmonary hypertension (PH). Recently, population-based epidemiology data from Norway estimated the point prevalence of adult-onset MCTD to be 3.8 per 100,000 and the mean annual incidence to be 2.1 per million per year, supporting the notion that MCTD is the least common CTD. Little is known about the etiology of MCTD, but recent genetic studies have confirmed that MCTD is a strongly HLA (human leukocyte antigen)-linked disease, as the HLA profiles of MCTD differ distinctly from the corresponding profiles of ethnically matched healthy controls and other CTDs.
In the first section of this review, we provide an update on the clinical, immunological, and genetic features of MCTD and discuss the relationship between MCTD and the other CTDs. Then we proceed to discuss the recent advances in therapy and our current understanding of prognosis and prognostic factors, especially those that are associated with the more serious pulmonary and cardiovascular complications of the disease. In the final section, we discuss some of the key, unresolved questions related to anti-RNP-associated diseases and indicate how these questions may be approached in future studies.
Watermelon stomach: Chronic renal failure and/or imatinib?
2015, Nephrologie et Therapeutique
L’estomac pastèque ou watermelon stomach ou syndrome d’ectasies vasculaires antrales gastriques (gastric antral vascular ectasia [GAVE] syndrome pour les Anglo-saxons) est une cause relativement rare mais non négligeable d’hémorragie digestive haute. Son diagnostic repose sur son aspect endoscopique très particulier mais peut parfois rester méconnu car confondu avec une gastropathie d’hypertension portale d’origine cirrhotique, alors que le traitement de ces deux pathologies est différent. Sa pathogénie reste encore obscure, même s’il s’associe souvent à diverses pathologies systémiques, parmi lesquelles des maladies auto-immunes et l’insuffisance rénale chronique. Le mécanisme responsable de ces ectasies vasculaires pourrait être lié à un stress mécanique des vaisseaux sous-muqueux du fait d’une dysfonction de la motilité péristaltique au niveau antro-pylorique en rapport avec des modifications neuro-hormonales vasoactives. Les traitements médicaux ne paraissent pas satisfaisants. Au sein des différentes thérapeutiques endoscopiques, la coagulation par plasma argon paraît actuellement le traitement de choix du fait de son efficacité et de son innocuité. Une antrectomie peut cependant être parfois nécessaire, mais au prix d’une morbi-mortalité notable. Récemment, l’imatinib (Glivec^®), thérapie ciblée de référence dans la leucémie myéloïde chronique, a pu être reconnu comme un facteur responsable du watermelon stomach et nous rapportons ici l’observation d’une telle pathologie survenue chez un patient à la fois hémodialysé et traité par Glivec^®.
Watermelon stomach or gastric antral vascular ectasia (GAVE) syndrome is an uncommon cause of sometimes severe upper gastro-intestinal bleeding. Essentially based on a pathognomonic endoscopic appearance, its diagnosis may be unrecognised because mistaken with portal hypertensive gastropathy, while treatment of these two entities is different. Its etiopathogeny remains still unclear, even if it is frequently associated with different systemic illnesses as hepatic cirrhosis, autoimmune disorders and chronic renal failure. The mechanism inducing these vascular ectasia may be linked with mechanical stress on submucosal vessels due to antropyloric peristaltic motility dysfunction modulated by neurohormonal vasoactive alterations. Because medical therapies are not very satisfactory, among the endoscopic modalities, argon plasma coagulation seems to be actually the first-line treatment because the most effective and safe. However, surgical antrectomy may be sometimes necessary. Recently GAVE syndrome appeared as a new adverse reaction of imatinib mesylate, one of the tyrosine kinase inhibitors used in chronic myeloid leukemia, and we report here the observation of such a pathology in one patient treated at the same time by haemodialysis and by imatinib mesylate for chronic myeloid leukemia.
Gastric vascular lesions in cirrhosis: Gastropathy and antral vascular ectasia
2015, Gastroenterologia y Hepatologia
La gastropatía de la hipertensión portal (GHP) es una complicación de la hipertensión portal (HTP) generalmente asociada a la cirrosis hepática (CH). Su etiopatogenia no está clara; se acepta, sin embargo, que la presencia de HTP es un factor imprescindible para su desarrollo. La GHP puede ser asintomática o manifestarse en forma de anemia ferropénica o hemorragia digestiva. Las lesiones endoscópicas varían desde un patrón en mosaico hasta manchas rojas difusas en los casos más graves; la localización más característica es el fundus. El tratamiento está indicado en caso de hemorragia, aguda o crónica como profilaxis secundaria. No hay datos suficientes para recomendar profilaxis primaria en pacientes que no han sangrado. Pueden utilizarse fármacos que disminuyen la presión portal, como los betabloqueantes no cardioselectivos, y/o tratamientos endoscópicos ablativos, como el argón. El papel del transarterial intrahepatic portosistemic shunt o shunt intrahepático portosistémico (TIPS) o la cirugía derivativa no ha sido suficientemente analizado. Por su parte, la ectasia vascular antral es una entidad poco frecuente en la CH cuya fisiopatología todavía se desconoce. Clínicamente, se comporta igual que la GHP y a nivel endoscópico suele presentarse como manchas rojas en antro. A menudo, es necesario realizar una biopsia para diferenciarla de la GHP. No disponemos de tratamiento médico efectivo, por lo que, en pacientes sintomáticos, se recomienda tratamiento ablativo endoscópico y, en casos graves, valorar antrectomía.
Portal hypertensive gastropathy (GHP) is a complication of portal hypertension usually associated with liver cirrhosis. The pathogenesis is unclear but the presence of portal hypertension is an essential factor for its development. GHP may be asymptomatic or present as gastrointestinal bleeding or iron deficiency anemia. Endoscopic lesions vary from a mosaic pattern to diffuse red spots; the most common location is the fundus. Treatment is indicated when there is acute or chronic bleeding, as secondary prophylaxis. There is insufficient evidence to recommend primary prophylaxis in patients who have never bled. Drugs that decrease portal pressure, such as non-cardioselective beta-blockers, and/or endoscopic ablative treatments, such as argon-beam coagulation, may be used. The role of transarterial intrahepatic portosystemic shunt) or bypass surgery has been insufficiently analyzed. Antral vascular ectasia (EVA) is a rare entity in liver cirrhosis, whose pathophysiology is still unknown. Clinical presentation is similar to that of GHP and endoscopy usually shows red spots in the antrum. Biopsy is often required to differentiate EVA from GHP. There is no effective medical therapy, so endoscopic ablative therapy and, in severe cases, antrectomy are recommended.
Approach to the Management of portal hypertensive gastropathy and gastric antral vascular ectasia
2014, Gastroenterology Clinics of North America
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There are no head-to-head trials comparing these techniques; they do differ in their safety profile. APC is a reasonably newer (Fig. 2), noncontact technique with lesser depth of coagulation and thus carries a lesser risk of gastric perforation as compared with YAG.24 YAG therapy is often complicated with gastric ulceration.
Medical and Endoscopic Therapies for Angiodysplasia and Gastric Antral Vascular Ectasia: A Systematic Review
2014, Clinical Gastroenterology and Hepatology
Citation Excerpt :
There were 10 case series on APC (n = 192) that found 21% of patients (0%–80%) had adverse events, no perforations (0%), 2% (1%–14%) failed therapy with 25% (0%–57%) overall mortality, and 12% (0%–50%) of mortality was therapy or bleeding related (Table 2).58–67 There were 10 case series on Nd:YAG therapy (n = 185) that found 20% of patients (0%–51%) had complications, 1.6% (0%–14%) had perforations, 6% (0%–13%) failed therapy, and there was 28% (9%–63%) overall mortality, and 10% (0%–25%) of mortality was therapy or bleeding related.68–75 A single case series on heater probe (n = 12) found 33% of patients had complications, but there were no perforations, therapy failures, or mortality (0%).76
Few studies have compared the efficacy and complications of endoscopic or medical therapies for bleeding angiodysplasias or gastric antral vascular ectasias (GAVE). We conducted a systematic review to evaluate therapies.
We performed a PubMed search for studies (written in English from January 1, 1980, through January 1, 2013) of medical or endoscopic treatment of bleeding angiodysplasias and GAVE. Measured outcomes included levels of hemoglobin, transfusion requirements, rebleeding rates, complications, treatment failures, and overall mortality.
We analyzed data from 63 studies that met inclusion criteria; 50 evaluated endoscopic treatment (1790 patients), 13 evaluated medical treatment (392 patients), and 12 were comparative studies. In patients with angiodysplasias, the combination of estrogen and progesterone did not significantly reduce bleeding episodes, compared with placebo (0.7/y vs 0.9/y, respectively), and increased mortality, compared with conservative therapy (33% vs 21%). A higher percentage of patients receiving octreotide were free of rebleeding at 1 and 2 years vs placebo (77% vs 55% and 68% vs 36%, respectively; P = .03). Thalidomide reduced the number of bleeding episodes (–8.96/y), compared with iron therapy (–1.38/y, P < .01), but neither treatment reduced mortality. More patients with GAVE treated by endoscopic band ligation were free from rebleeding (92%) than those treated with argon plasma coagulation (32%, P = .01).
In a systematic review, we found a low quality of evidence to support treatment of angiodysplasias with thalidomide or the combination of estrogen and progesterone and insufficient evidence to support treatment with octreotide. There is also insufficient evidence for endoscopic therapy of angiodysplasia or GAVE. Well-designed randomized controlled trials are needed to study the efficacy and complications of medical and endoscopic treatments for patients with angiodysplasias or GAVE.
External-beam radiotherapy: A realistic therapeutic option for the gastric antral vascular ectasia
2012, Reports of Practical Oncology and Radiotherapy
Citation Excerpt :
Nd:YAG laser has been widely used but it rarely provides a complete cure. Most patients need several sessions and between 14% and 50% continue with the need of transfusion during follow-up.2,5,9 Endoscopic argon-plasma coagulation (APC) also offers similar clinical results to those achieved with Nd:YAG laser with a limited penetration, which reduces ulceration and perforation.10
The gastric antral vascular ectasia (GAVE) is a well recognizable endoscopic entity characterized by the presence of multiple linear angioectatic vessels predominantly located in the antrum, with a typical appearance of “watermelon stomach”. This condition typically affects elderly females presenting as iron-deficiency anaemia due to chronic gastric bleeding. Standard treatment is endoscopic ablation of the gastric mucosa. For non-responders, radical surgery is considered a curative treatment but with considerable morbidity and mortality. Radiation therapy is a well-known alternative for many benign diseases, including anomalous vascular hyperproliferative diseases, although its role has not been defined for GAVE. The present case illustrates the efficacy and tolerance of radiotherapy in the treatment of symptomatic gastric watermelon.

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^☆: From the Division of Gastroenterology, The Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, Pennsylvania, and Geisinger Medical Center, Danville, Pennsylvania.

^☆☆: Reprint requests: Thomas J. McGarrity, MD, Associate Professor of Medicine, Division of Gastroenterology, The Milton S. Hershey Medical Center, The Pennsylvania State University, PO Box 850, 500 University Drive, Hershey, PA 17033.

^★: 37/1/55009

^★★: GASTROINTESTINAL ENDOSCOPY

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The watermelon stomach: Long-term outcome in patients treated with ND:YAG laser therapy☆,☆☆,★,★★

Abstract

Section snippets

Patients

Patient characteristics

DISCUSSION

Acknowledgements

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Arteriovenous malformation of the stomach: radiologic and endoscopic features

American Journal of Digestive Diseases

Diffuse gastric antral vascular ectasia: cause of chronic gastrointestinal blood loss

Endoscopy