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Efficacy of argon plasma coagulation for gastric antral vascular ectasia associated with chronic liver disease
Hepatology Research 32 (2005) 121–126
Efficacy of argon plasma coagulation for gastric antral vascular ectasia associated with chronic liver disease Takahiro Sato ∗ , Katsu Yamazaki, Jouji Toyota, Yoshiyasu Karino, Takumi Ohmura, Jun Akaike, Yasuaki Kuwata, Toshihiro Suga Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan Received 7 February 2005; received in revised form 23 March 2005; accepted 21 April 2005
Abstract Gastric antral vascular ectasia (GAVE) is a rare cause of chronic gastrointestinal bleeding. The aim of this study was to evaluate the relationship between GAVE with cirrhotic patients and liver dysfunction, portal hypertension and the safety and efficacy of argon plasma coagulation (APC) in treating GAVE with cirrhotic patients. Eight cirrhotic patients with the characteristic endoscopic findings of GAVE were registered. In this study, APC was performed for GAVE in all eight patients. The patients-liver function was classified by ChildPugh classification and classifications were: two class A, five class B and one class C (mean score: 7.8). Five patients had previously received prophylactic endoscopic injection sclerotherapy for esophageal varices and one had esophageal varices. Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices had been performed in other one patient. Portal hypertensive gastropathy (PHG) was recognized in only one case. APC was performed in all eight patients and one to three treatment sessions were needed (mean: 1.8 sessions). No complications were observed in the initial treatment. During follow-up, endoscopies revealed the recurrence of GAVE in two patients requiring further treatment by APC (recurrence rate: 25%). After APC treatment, the recurrence of GAVE was not observed with endoscopy in the other six patients. The results suggest that GAVE is related to severe liver damage and portal hypertension in cirrhotic patients. APC is a safe and effective treatment against GAVE. © 2005 Elsevier B.V. All rights reserved. Keywords: Argon plasma coagulation; Gastric antral vascular ectasia; Esophageal varices; Liver cirrhosis; Portal hypertension
1. Introduction Gastric antral vascular ectasia (GAVE) is a rare cause of chronic gastrointestinal bleeding, often presenting as irondeficiency anemia, melena or rarely, hematemesis [1–4]. The endoscopic findings are found almost exclusively in the antrum and red spots are either aggregated in linear stripes or diffusely spread. Histologically, dilated mucosal capillaries with fibrin thrombi and fibromuscular hyperplasia of the lamina propria are seen without inflammation [5]. The diagnosis of GAVE is achieved on the basis of endoscopic and histological appearance. GAVE has been associated with cirrhosis, renal failure, bone marrow transplantation, scleroderma. The majority of GAVE patients have underlying cirrhosis ∗
Corresponding author. Tel.: +81 11 261 5331; fax: +81 11 271 5320. E-mail address: [email protected] (T. Sato).
1386-6346/$ – see front matter © 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.hepres.2005.04.004
and portal hypertension. However, Spahr et al. have reported that GAVE is not directly related to portal hypertension [6]. The optimal treatment of GAVE is not known. Argon plasma coagulation (APC) is a relatively new non-contact electrocoagulation technique. Grund et al. have reported on the first experiences with APC as an option in the treatment of gastrointestinal hemorrhage [7]. The aim of this study was to evaluate the relationship between GAVE with cirrhotic patients and liver dysfunction, portal hypertension and the safety and efficacy of APC in treating GAVE with cirrhotic patients.
2. Patients and methods Between January 2001 and December 2003, eight patients with the characteristic endoscopic findings of GAVE were
122
T. Sato et al. / Hepatology Research 32 (2005) 121–126
registered. The subjects included three males and five females ranging in age from 57 to 78 years (mean: 67.9). The underlying pathologies of chronic liver diseases were liver cirrhosis in seven patients and cirrhosis associated with hepatocellular carcinoma in one. The etiologies of their liver diseases were as follows: hepatitis B surface antigen (HBs Ag) positive in one case, anti-HCV antibody positive (HCV) in four, alcoholic liver diseases in one and unknown in two. All eight patients had iron-deficiency anemia and five patients also had a history of melena. In this study, APC was performed for GAVE in all eight patients. The unit used in this study was the standard APC equipment consisting of a high-frequency electrosurgical generator (ICC 350, Tuebingen, ERBE, Germany) an automatically regulated argon source (APC 300) and a flexible APC probe. The APC probe was a 2.3 mm Teflon-coated catheter with a heat-resistant ceramic tip, which could be passed through the working channel of an endoscope. The 60 W electrical power and argon gas flow was 2 L/min. Coagulation time was under 2 s. Follow-up periods after APC were from 12 to 47 months (mean 28 months).
3. Results In two patients (cases 1 and 2), active oozing bleeding from GAVE had been observed endoscopically. In three patients (cases 4–6), marked anemia was recognized and gastrointestinal bleeding (melena) was observed in five cases (cases 1, 2, 4, 6 and 8). The liver functioning of the patients was classified by Child-Pugh classification and the classifications were: two class A, five class B and one class C (mean score: 7.8). Five patients (cases 1, 2, 5, 6 and 7) had previously received prophylactic endoscopic injection sclerotherapy (EIS) for esophageal varices. Case 4 had esophageal varices (Lm, F2, Cw, RC(−)) according to The General Rules for Recording Endoscopic Findings of Esophageal Varices prepared by the Japanese Research Committee on Portal Hypertension [8]. Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices had been performed in other one patient (case 8). Portal hypertensive gastropathy (PHG) was recognized in only one case (case 3) and this case showed mild PHG (Table 1). Antral motility in these Table 1 Characteristics of GAVE patients Case
Gender
Liver disease
C-P score
EV
PHG
1 2 3 4 5 6 7 8
F F M F F M M F
LC LC LC LC LC LC LC LC + HCC
B (8) B (7) A (5) B (8) B (9) C (10) A (6) B (9)
(−) FORC (−) (−) LmF2CwRC (−) LmF1CbRC (−) F0RC (+) (−) (−)
(−) (−) (+) (−) (−) (−) (−) (−)
LC: liver cirrhosis; C-P: Child-Pugh; EV: esophageal varices; PHG: portal hypertensive gastropathy.
GAVE was frequent and intense in all eight patients. Hypergastrinemia was discerned in three of the five patients tested. APC was performed in all eight patients and treatment was commenced at the pylorus, moving proximally. The goal of treatment was the formation of pale yellow coagulum over the vascular lesions. One to three treatment sessions were needed (mean: 1.8 sessions). No complications were observed in the initial treatment. Endoscopic findings after APC revealed both the small ulcers and the improvement of GAVE in all eight patients. During follow-up, endoscopies revealed the recurrence of GAVE in two patients requiring further treatment by APC (recurrence rate: 25%). However, further treatment by APC was effective in these two cases. On the other hand, after APC treatment, the recurrence of GAVE was not observed with endoscopy in other six patients.
4. Case presentation (a 69-year-old female with C type liver cirrhosis) The fibergastroscopic examination revealed active oozing bleeding from mucosal diffuse spotty redness spreading over the antrum of the stomach (Fig. 1). The mucosal spotty redness revealed telangiectasia with endoscopic findings (Fig. 2) and an ultrasonic microprobe (UMP) using 20 MHz under constant filling of deaerated water in the stomach showed small low echoic spots within the second (mucosa) and third (submucosa) sonographic layers (Fig. 3). We diagnosed GAVE based upon these findings. She was treated with APC and the probe was applied to the lesion beginning at the pylorus and proceeding proximally. The sessions of APC were repeated 1 week later and three sessions were performed in this patient. The fibergastroscopic examination 20 days after treatment showed the improvement of GAVE (Fig. 4). The additional APC was performed 3 months later on the recurrent GAVE in this patient. After the additional APC treatment, the recurrence of GAVE was not observed with endoscopy and the low echoic spots within the second sonographic layer disappeared via UMP.
5. Discussion The etiology of GAVE remains unknown and it is thought to encompass a variety of conditions including autoimmune disease, liver cirrhosis, portal hypertension, chronic renal failure, cardiovascular disease, achlorhydria, severe hypochlorhydria, hypothyroidism and diabetes mellitus [9–16]. In Gostouts article, atrophic gastritis occurred in 19 of 19 (100%) with biopsies and hypergastrinemia was observed in 25 of 33 (76%) tested [9]. Gastrin may play a role in the pathogenesis of GAVE. In our cases, hypergastrinemia was discerned in three of five patients tested. However, it may not be fundamental and also, Ikeda et al. have reported that the development of GAVE associated with cirrhosis was concerned with the time courses [17,18].
T. Sato et al. / Hepatology Research 32 (2005) 121–126
Fig. 1. Endoscopic examination revealed mucosal diffuse spotty redness spreading over the antrum of the stomach.
Fig. 2. The mucosal spotty redness revealed telangiectasia with endoscopic findings.
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T. Sato et al. / Hepatology Research 32 (2005) 121–126
Fig. 3. Ultrasonic microprobe showed small low echoic spots within the second (mucosa) and third (submucosa) sonographic layers.
Fig. 4. Endoscopic examination 20 days after treatment showed the improvement of gastric antral vascular ectasia.
T. Sato et al. / Hepatology Research 32 (2005) 121–126
GAVE has an endoscopic appearance involving diffuse, punctate and vascular telangiectasia in the entire antral area, in which the dilatation of mucosal capillaries results in gastrointestinal bleeding. The typical histopathological appearance of GAVE consists of hypertrophy of the antral mucosa, dilatation of mucosal capillaries with focal thrombosis and fibromuscular hyperplasia of the lamina propria [1,5,9,16,19,20]. UMP showed small low echoic images within the second and third sonographic layers in case presentation in similar to Shudos report [21]. These low echoic images suggest the dilatation of mucosal and submucosal capillaries. Several reports explain the elevated antral motility for GAVE [22,23]. In our cases, antral motility was frequent and intense. All of the present cases are associated with liver cirrhosis. GAVE requiring therapy seems to depend the severity of liver function. In our patients, the mean score of Child-Pugh classification was 7.8. Four patients had previously received prophylactic EIS for esophageal varices and one patient had esophageal varices, and B-RTO for gastric varices had been performed in other one patient, indicating the relationship between GAVE and portal hypertension. However, PHG was recognized in only one case. We suggest that GAVE is related to not only portal hypertension but also hypergastrinemia, elevated antral motility. Surgical anterectomy has been performed mainly for GAVE before 1990 [1]. However, surgery carries a significant risk of mortality in cirrhotic patients. Recently, endoscopic techniques or pharmacological agents have become the first choice treatment for GAVE. Several endoscopic treatments have been performed successfully to treat GAVE, including laser [24], electrocoagulation [25,26], heat probe [27] and APC [28–32]. APC is a new modality of non-contact electrocoagulation that applies high frequency electronic energy into tissue to cause defined thermal effects, which can be used for thermal devitalization of the tissue as well as hemostasis. The argon plasma seeks precisely the tissue surface with the lowest electrical impedance. Therefore, the tissue is coagulated to an even depth across the entire surface and the danger of perforation is lower than with conventional coagulation procedures or YAG Laser [29]. The mucosal damage is mostly dependent on electrical power output and duration of application of APC. Probst et al. reported deep antral ulcers after APC treatment with an electrical power output of 60 W. However, it is no problem with coagulation time being under 2 s. The additional advantages of APC are as follows: uncomplicated technique, reasonably priced and possessing mobility (it can be employed quickly and at any place or time). One disadvantage of APC is the distention of the gastrointestinal tract due to argon gas insufflation during treatment [7]. After APC treatment, the recurrence of GAVE was not observed with endoscopy in six of eight patients in our cases. However, further treatment by APC was effective in two recurrent patients of GAVE.
125
In conclusion, the results suggest that GAVE is related to severe liver damage in cirrhotic patients. APC is a safe and effective treatment against GAVE.
References [1] Jabbari M, Cherry R, Lough JO, et al. Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology 1984;87:1165–70. [2] Park RHR, Russell RI. Watermelon stomach. Br J Surg 1991;78:395–6. [3] Gretz JE, Achem SR. The watermelon stomach: clinical presentation, diagnosis, and treatment. Am J Gastroenterol 1999;94:2909–11. [4] Szold A, Katz LB, Lewis BS. Surgical approach to gastrointestinal bleeding. Am J Surg 1992;163:90–3. [5] Suit PF, Petras RE, Bauer TW, et al. Gastric antral vascular ectasia. A histologic and morphometric study of watermelon stomach. Am J Surg Pathol 1987;11:750–7. [6] Spahr L, Villeneuve JP, Dufresne MP, et al. Gastric antral vascular ectasia in cirrhotic patients: absence of relation with portal hypertension. Gut 1999;544:739–42. [7] Grund KE, Storek D, Farin G. Endoscopic argon plasma coagulation (APC): first clinical experiences in flexible endoscopy. Endosc Surg 1994;2:42–6. [8] Japanese Research Society for Portal Hypertension. The general rules for recording endoscopic findings of esophageal varices–revised edition. Acta Hepatol Jpn 1991;33:277–81 [in Japanese with English abstract]. [9] Gostout CJ, Viggiano TR, Ahlquist DA, et al. The clinical endoscopic spectrum of the watermelon stomach. J Clin Gastroenterol 1992;15:256–63. [10] Lee FI, Costello F, Flanagan N, et al. Diffuse antral vascular ectasia. Gastrointest Endosc 1984;30:87–90. [11] Arendt T, Barten M, Lakner V, et al. Diffuse gastric antral vascular ectasia: cause of chronic gastrointestinal blood loss. Endoscopy 1987;19:218–20. [12] Kamberoglou D, Kakkak M, Bennett JR. Case of watermelon stomach successfully treated by heat probe coagulation. Gut 1992;33: 964. [13] Zuckerman GR, Cornette GL, Clouse RE, et al. Upper gastrointestinal bleeding in patients with chronic renal failure. Ann Intern Med 1985;102:588–92. [14] Dave P, Romeu J, Antonelli A, et al. Gastrointestinal telangiectasias: a source of bleeding patients receiving hemodialysis. Arch Intern Med 1984;14:1781–3. [15] Cunningham JT. Gastric telangiectasias in chronic hemodialysis patients: a case report of six cases. Gastroenterology 1981;81:1131–3. [16] Borsch G. Diffuse antral vascular ectasia: the watermelon stomach revised. Am J Gastroenterol 1987;82:1333–4. [17] Ikeda M, Ishida H, Nakamura E, et al. An endoscopic followup study of the development of diffuse antral vascular ectasia. Endoscopy 1996;28:390–3. [18] Ikeda M, Hayashi N, Imamura E, et al. Endoscopic follow-up study of development of gastric antral vascular ectasia associated with liver cirrhosis. J Gastroenterol 1997;32:587–92. [19] Gilliam III JH, Geisinger KR, Wu WC, et al. Endoscopic biopsy is diagnostic in gastric antral vascular ectasia: the watermelon stomach. Dig Dis Sci 1989;34:885–8. [20] Wolf DC, Brooks WS. Antral vascular ectasia of liver cirrhosis: Endoscopic laser therapy. Gastrointest Endosc 1986;32:139–40. [21] Shudo R, Yazaki Y, Sakurai S, et al. Diffuse antral vascular ectasia: EUS after argon plasma coagulation. Gastrointest Endosc 2001;54:623. [22] Lowes JR, Rode J. Neuroendocrine cell proliferation in gastric antral vascular ectasia. Gastroenterology 1989;97:207–12.
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[23] Charneau J, Petit R, Cales P, et al. Antral motility in patients with cirrhosis with or without gastric antral vascular ectasia. Gut 1995;37:488–92. [24] Bourke MJ, Hope RL, Boyd P, et al. Endoscopic laser therapy for watermelon stomach. J Gastroenterol Hepatol 1996;11:832–4. [25] Yamada M, Ichikawa M, Takahara O, et al. Gastroduodenal vascular ectasia in patients with liver cirrhosis. Dig Endosc 1999;11:241–5. [26] Bimmoeller KF, Karon RM. Bipolar electrocoagulation for watermelon stomach. Gastrointest Endosc 1990;36:399–402. [27] Petrini JL, Johnson JH. Heat probe treatment for antral vascular ectasia. Gastrointest Endosc 1989;35:324–8. [28] Probst A, Scheubel R, Wienbeck M. Treatment of watermelon stomach (GAVE syndrome) by means of endoscopic argon plasma
[29]
[30]
[31] [32]
coagulation (APC): long-term outcome. Z Gastroenterol 2001;39: 447–52. Wahab PJ, Mulder CJ, den Hartog G, et al. Argon plasma coagulation in flexible gastrointestinal endoscopy. Pilot experiences. Endoscopy 1997;29:176–81. Canard JM, Vedrenne B. Clinical application of argon plasma coagulation in gastrointestinal endoscopy: has the time come to replace the laser? Endoscopy 2001;33:353–7. Yusoff I, Brennan F, Ormonde D, et al. Argon plasma coagulation for treatment of watermelon stomach. Endoscopy 2002;34:407–10. Sou S, Nagahama T, Nomura H, et al. Remarkable effectiveness of endoscopic argon plasma coagulation against diffuse antral vascular ectasia. Dig Endosc 2004;16:166–8.
Efficacy of argon plasma coagulation for gastric antral vascular ectasia associated with chronic liver disease Takahiro Sato ∗ , Katsu Yamazaki, Jouji Toyota, Yoshiyasu Karino, Takumi Ohmura, Jun Akaike, Yasuaki Kuwata, Toshihiro Suga Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan Received 7 February 2005; received in revised form 23 March 2005; accepted 21 April 2005
Abstract Gastric antral vascular ectasia (GAVE) is a rare cause of chronic gastrointestinal bleeding. The aim of this study was to evaluate the relationship between GAVE with cirrhotic patients and liver dysfunction, portal hypertension and the safety and efficacy of argon plasma coagulation (APC) in treating GAVE with cirrhotic patients. Eight cirrhotic patients with the characteristic endoscopic findings of GAVE were registered. In this study, APC was performed for GAVE in all eight patients. The patients-liver function was classified by ChildPugh classification and classifications were: two class A, five class B and one class C (mean score: 7.8). Five patients had previously received prophylactic endoscopic injection sclerotherapy for esophageal varices and one had esophageal varices. Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices had been performed in other one patient. Portal hypertensive gastropathy (PHG) was recognized in only one case. APC was performed in all eight patients and one to three treatment sessions were needed (mean: 1.8 sessions). No complications were observed in the initial treatment. During follow-up, endoscopies revealed the recurrence of GAVE in two patients requiring further treatment by APC (recurrence rate: 25%). After APC treatment, the recurrence of GAVE was not observed with endoscopy in the other six patients. The results suggest that GAVE is related to severe liver damage and portal hypertension in cirrhotic patients. APC is a safe and effective treatment against GAVE. © 2005 Elsevier B.V. All rights reserved. Keywords: Argon plasma coagulation; Gastric antral vascular ectasia; Esophageal varices; Liver cirrhosis; Portal hypertension
1. Introduction Gastric antral vascular ectasia (GAVE) is a rare cause of chronic gastrointestinal bleeding, often presenting as irondeficiency anemia, melena or rarely, hematemesis [1–4]. The endoscopic findings are found almost exclusively in the antrum and red spots are either aggregated in linear stripes or diffusely spread. Histologically, dilated mucosal capillaries with fibrin thrombi and fibromuscular hyperplasia of the lamina propria are seen without inflammation [5]. The diagnosis of GAVE is achieved on the basis of endoscopic and histological appearance. GAVE has been associated with cirrhosis, renal failure, bone marrow transplantation, scleroderma. The majority of GAVE patients have underlying cirrhosis ∗
Corresponding author. Tel.: +81 11 261 5331; fax: +81 11 271 5320. E-mail address: [email protected] (T. Sato).
1386-6346/$ – see front matter © 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.hepres.2005.04.004
and portal hypertension. However, Spahr et al. have reported that GAVE is not directly related to portal hypertension [6]. The optimal treatment of GAVE is not known. Argon plasma coagulation (APC) is a relatively new non-contact electrocoagulation technique. Grund et al. have reported on the first experiences with APC as an option in the treatment of gastrointestinal hemorrhage [7]. The aim of this study was to evaluate the relationship between GAVE with cirrhotic patients and liver dysfunction, portal hypertension and the safety and efficacy of APC in treating GAVE with cirrhotic patients.
2. Patients and methods Between January 2001 and December 2003, eight patients with the characteristic endoscopic findings of GAVE were
122
T. Sato et al. / Hepatology Research 32 (2005) 121–126
registered. The subjects included three males and five females ranging in age from 57 to 78 years (mean: 67.9). The underlying pathologies of chronic liver diseases were liver cirrhosis in seven patients and cirrhosis associated with hepatocellular carcinoma in one. The etiologies of their liver diseases were as follows: hepatitis B surface antigen (HBs Ag) positive in one case, anti-HCV antibody positive (HCV) in four, alcoholic liver diseases in one and unknown in two. All eight patients had iron-deficiency anemia and five patients also had a history of melena. In this study, APC was performed for GAVE in all eight patients. The unit used in this study was the standard APC equipment consisting of a high-frequency electrosurgical generator (ICC 350, Tuebingen, ERBE, Germany) an automatically regulated argon source (APC 300) and a flexible APC probe. The APC probe was a 2.3 mm Teflon-coated catheter with a heat-resistant ceramic tip, which could be passed through the working channel of an endoscope. The 60 W electrical power and argon gas flow was 2 L/min. Coagulation time was under 2 s. Follow-up periods after APC were from 12 to 47 months (mean 28 months).
3. Results In two patients (cases 1 and 2), active oozing bleeding from GAVE had been observed endoscopically. In three patients (cases 4–6), marked anemia was recognized and gastrointestinal bleeding (melena) was observed in five cases (cases 1, 2, 4, 6 and 8). The liver functioning of the patients was classified by Child-Pugh classification and the classifications were: two class A, five class B and one class C (mean score: 7.8). Five patients (cases 1, 2, 5, 6 and 7) had previously received prophylactic endoscopic injection sclerotherapy (EIS) for esophageal varices. Case 4 had esophageal varices (Lm, F2, Cw, RC(−)) according to The General Rules for Recording Endoscopic Findings of Esophageal Varices prepared by the Japanese Research Committee on Portal Hypertension [8]. Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices had been performed in other one patient (case 8). Portal hypertensive gastropathy (PHG) was recognized in only one case (case 3) and this case showed mild PHG (Table 1). Antral motility in these Table 1 Characteristics of GAVE patients Case
Gender
Liver disease
C-P score
EV
PHG
1 2 3 4 5 6 7 8
F F M F F M M F
LC LC LC LC LC LC LC LC + HCC
B (8) B (7) A (5) B (8) B (9) C (10) A (6) B (9)
(−) FORC (−) (−) LmF2CwRC (−) LmF1CbRC (−) F0RC (+) (−) (−)
(−) (−) (+) (−) (−) (−) (−) (−)
LC: liver cirrhosis; C-P: Child-Pugh; EV: esophageal varices; PHG: portal hypertensive gastropathy.
GAVE was frequent and intense in all eight patients. Hypergastrinemia was discerned in three of the five patients tested. APC was performed in all eight patients and treatment was commenced at the pylorus, moving proximally. The goal of treatment was the formation of pale yellow coagulum over the vascular lesions. One to three treatment sessions were needed (mean: 1.8 sessions). No complications were observed in the initial treatment. Endoscopic findings after APC revealed both the small ulcers and the improvement of GAVE in all eight patients. During follow-up, endoscopies revealed the recurrence of GAVE in two patients requiring further treatment by APC (recurrence rate: 25%). However, further treatment by APC was effective in these two cases. On the other hand, after APC treatment, the recurrence of GAVE was not observed with endoscopy in other six patients.
4. Case presentation (a 69-year-old female with C type liver cirrhosis) The fibergastroscopic examination revealed active oozing bleeding from mucosal diffuse spotty redness spreading over the antrum of the stomach (Fig. 1). The mucosal spotty redness revealed telangiectasia with endoscopic findings (Fig. 2) and an ultrasonic microprobe (UMP) using 20 MHz under constant filling of deaerated water in the stomach showed small low echoic spots within the second (mucosa) and third (submucosa) sonographic layers (Fig. 3). We diagnosed GAVE based upon these findings. She was treated with APC and the probe was applied to the lesion beginning at the pylorus and proceeding proximally. The sessions of APC were repeated 1 week later and three sessions were performed in this patient. The fibergastroscopic examination 20 days after treatment showed the improvement of GAVE (Fig. 4). The additional APC was performed 3 months later on the recurrent GAVE in this patient. After the additional APC treatment, the recurrence of GAVE was not observed with endoscopy and the low echoic spots within the second sonographic layer disappeared via UMP.
5. Discussion The etiology of GAVE remains unknown and it is thought to encompass a variety of conditions including autoimmune disease, liver cirrhosis, portal hypertension, chronic renal failure, cardiovascular disease, achlorhydria, severe hypochlorhydria, hypothyroidism and diabetes mellitus [9–16]. In Gostouts article, atrophic gastritis occurred in 19 of 19 (100%) with biopsies and hypergastrinemia was observed in 25 of 33 (76%) tested [9]. Gastrin may play a role in the pathogenesis of GAVE. In our cases, hypergastrinemia was discerned in three of five patients tested. However, it may not be fundamental and also, Ikeda et al. have reported that the development of GAVE associated with cirrhosis was concerned with the time courses [17,18].
T. Sato et al. / Hepatology Research 32 (2005) 121–126
Fig. 1. Endoscopic examination revealed mucosal diffuse spotty redness spreading over the antrum of the stomach.
Fig. 2. The mucosal spotty redness revealed telangiectasia with endoscopic findings.
123
124
T. Sato et al. / Hepatology Research 32 (2005) 121–126
Fig. 3. Ultrasonic microprobe showed small low echoic spots within the second (mucosa) and third (submucosa) sonographic layers.
Fig. 4. Endoscopic examination 20 days after treatment showed the improvement of gastric antral vascular ectasia.
T. Sato et al. / Hepatology Research 32 (2005) 121–126
GAVE has an endoscopic appearance involving diffuse, punctate and vascular telangiectasia in the entire antral area, in which the dilatation of mucosal capillaries results in gastrointestinal bleeding. The typical histopathological appearance of GAVE consists of hypertrophy of the antral mucosa, dilatation of mucosal capillaries with focal thrombosis and fibromuscular hyperplasia of the lamina propria [1,5,9,16,19,20]. UMP showed small low echoic images within the second and third sonographic layers in case presentation in similar to Shudos report [21]. These low echoic images suggest the dilatation of mucosal and submucosal capillaries. Several reports explain the elevated antral motility for GAVE [22,23]. In our cases, antral motility was frequent and intense. All of the present cases are associated with liver cirrhosis. GAVE requiring therapy seems to depend the severity of liver function. In our patients, the mean score of Child-Pugh classification was 7.8. Four patients had previously received prophylactic EIS for esophageal varices and one patient had esophageal varices, and B-RTO for gastric varices had been performed in other one patient, indicating the relationship between GAVE and portal hypertension. However, PHG was recognized in only one case. We suggest that GAVE is related to not only portal hypertension but also hypergastrinemia, elevated antral motility. Surgical anterectomy has been performed mainly for GAVE before 1990 [1]. However, surgery carries a significant risk of mortality in cirrhotic patients. Recently, endoscopic techniques or pharmacological agents have become the first choice treatment for GAVE. Several endoscopic treatments have been performed successfully to treat GAVE, including laser [24], electrocoagulation [25,26], heat probe [27] and APC [28–32]. APC is a new modality of non-contact electrocoagulation that applies high frequency electronic energy into tissue to cause defined thermal effects, which can be used for thermal devitalization of the tissue as well as hemostasis. The argon plasma seeks precisely the tissue surface with the lowest electrical impedance. Therefore, the tissue is coagulated to an even depth across the entire surface and the danger of perforation is lower than with conventional coagulation procedures or YAG Laser [29]. The mucosal damage is mostly dependent on electrical power output and duration of application of APC. Probst et al. reported deep antral ulcers after APC treatment with an electrical power output of 60 W. However, it is no problem with coagulation time being under 2 s. The additional advantages of APC are as follows: uncomplicated technique, reasonably priced and possessing mobility (it can be employed quickly and at any place or time). One disadvantage of APC is the distention of the gastrointestinal tract due to argon gas insufflation during treatment [7]. After APC treatment, the recurrence of GAVE was not observed with endoscopy in six of eight patients in our cases. However, further treatment by APC was effective in two recurrent patients of GAVE.
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In conclusion, the results suggest that GAVE is related to severe liver damage in cirrhotic patients. APC is a safe and effective treatment against GAVE.
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