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Watermelon stomach in a uremia patient
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http://www.kidney-international.org & 2010 International Society of Nephrology Kidney International (2010) 78, 821; doi:10.1038/ki.2010.234
Watermelon stomach in a uremia patient Wei-Hung Lin1,2, Meng-Fu Cheng1,2, Hsiu-Chi Cheng1,2 and Junne-Ming Sung2 1
Institute of Clinical Medicine, Department of Internal Medicine, National Cheng-Kung University Hospital, Tainan, Taiwan, ROC and Department of Internal Medicine, College of Medicine, National Cheng-Kung University, Tainan, Taiwan, ROC
2
Correspondence: Junne-Ming Sung, Department of Internal Medicine, College of Medicine, National Chen-Kung University, 138 Sheng-Li Road, Tainan 70428, Taiwan, ROC. E-mail: [email protected]
Figure 1 | Ectatic vessels along the longitudinal folds of the antrum.
Figure 2 | Argon plasma coagulation of watermelon stomach.
A 38-year-old woman with end-stage renal disease on maintenance hemodialysis for 7 years was referred with anemia and melena. She denied previous history of liver, heart, or autoimmune disease, and the first episode of melena with anemia (hematocrit of 26%) was noted 4 months ago. Panendoscopic examination at the referring hospital revealed multiple esophageal ulcers, gastric ulcers, and gastritis, and the biopsy of gastric mucosa showed chronic inflammation without Helicobacter pylori infection. Recurrent melena was frequently noted, with the hematocrit level being 22–27% despite treatment with lansoprazole, iron, several units of packed red blood cell transfusions (28 units in 4 months), and large doses of erythropoietin. A repeated panendoscopic examination at our center revealed gastric antral vascular ectasias (GAVE, watermelon stomach, Figure 1), which were treated by five courses of endoscopic argon plasma coagulation (Figure 2) and oral estrogen–progesterone therapy. Two
and a half years later, the patient has been doing well without any recurrence of disease. Watermelon stomach (GAVE) is named for the characteristic endoscopic findings of longitudinal red columns radiating to the pylorus, and its histopathological features show dilated and thrombosed capillaries in the lamina propria. The condition has been associated with systemic sclerosis, portal hypertension, and chronic renal failure. It should be considered in renal failure patients with recurrent upper gastrointestinal bleeding and those with refractory iron-deficiency anemia. The optimum treatment is not known; however, conventional therapies (histamine-2 blockers, proton-pump inhibitors, and sucralfate) for acid-peptic disease are not effective; argon plasma coagulation is often successful and is the treatment of choice. In addition, several case reports have reported on the efficacy of estrogen–progesterone combination. Surgical antrectomy is usually reserved for refractory cases.
Kidney International (2010) 78, 821
821
http://www.kidney-international.org & 2010 International Society of Nephrology Kidney International (2010) 78, 821; doi:10.1038/ki.2010.234
Watermelon stomach in a uremia patient Wei-Hung Lin1,2, Meng-Fu Cheng1,2, Hsiu-Chi Cheng1,2 and Junne-Ming Sung2 1
Institute of Clinical Medicine, Department of Internal Medicine, National Cheng-Kung University Hospital, Tainan, Taiwan, ROC and Department of Internal Medicine, College of Medicine, National Cheng-Kung University, Tainan, Taiwan, ROC
2
Correspondence: Junne-Ming Sung, Department of Internal Medicine, College of Medicine, National Chen-Kung University, 138 Sheng-Li Road, Tainan 70428, Taiwan, ROC. E-mail: [email protected]
Figure 1 | Ectatic vessels along the longitudinal folds of the antrum.
Figure 2 | Argon plasma coagulation of watermelon stomach.
A 38-year-old woman with end-stage renal disease on maintenance hemodialysis for 7 years was referred with anemia and melena. She denied previous history of liver, heart, or autoimmune disease, and the first episode of melena with anemia (hematocrit of 26%) was noted 4 months ago. Panendoscopic examination at the referring hospital revealed multiple esophageal ulcers, gastric ulcers, and gastritis, and the biopsy of gastric mucosa showed chronic inflammation without Helicobacter pylori infection. Recurrent melena was frequently noted, with the hematocrit level being 22–27% despite treatment with lansoprazole, iron, several units of packed red blood cell transfusions (28 units in 4 months), and large doses of erythropoietin. A repeated panendoscopic examination at our center revealed gastric antral vascular ectasias (GAVE, watermelon stomach, Figure 1), which were treated by five courses of endoscopic argon plasma coagulation (Figure 2) and oral estrogen–progesterone therapy. Two
and a half years later, the patient has been doing well without any recurrence of disease. Watermelon stomach (GAVE) is named for the characteristic endoscopic findings of longitudinal red columns radiating to the pylorus, and its histopathological features show dilated and thrombosed capillaries in the lamina propria. The condition has been associated with systemic sclerosis, portal hypertension, and chronic renal failure. It should be considered in renal failure patients with recurrent upper gastrointestinal bleeding and those with refractory iron-deficiency anemia. The optimum treatment is not known; however, conventional therapies (histamine-2 blockers, proton-pump inhibitors, and sucralfate) for acid-peptic disease are not effective; argon plasma coagulation is often successful and is the treatment of choice. In addition, several case reports have reported on the efficacy of estrogen–progesterone combination. Surgical antrectomy is usually reserved for refractory cases.
Kidney International (2010) 78, 821
821