Endoscopic band ligation versus argon plasma coagulation for gastric antral vascular ectasia associated with liver diseases

Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan.
Digestive Endoscopy (Impact Factor: 2.06). 07/2012; 24(4):237-42. DOI: 10.1111/j.1443-1661.2011.01221.x
Source: PubMed


The aim of the present study was to evaluate the clinicopathological features and the efficacy of endoscopic treatments in treating gastric antral vascular ectasia (GAVE) in association with liver diseases.
Thirty-four patients with the characteristic endoscopic findings of GAVE were enrolled. Endoscopic treatments were carried out for all 34 patients, including argon plasma coagulation (APC) in 22 patients and endoscopic band ligation (EBL) in 12 patients.
All 34 patients had iron-deficiency anemia and 21 patients also had a history of tarry stools. The underlying pathologies of chronic liver diseases were liver cirrhosis in 26 patients, liver cirrhosis associated with hepatocellular carcinoma in six, and idiopathic portal hypertension in two. The liver function was classified by Child-Pugh classification: class A (n=6), class B (n=21), and class C (n=7). Antral motility was frequent and intense in all 34 GAVE patients. In the 22 patients who received APC, endoscopies revealed the recurrence of GAVE in 15 patients requiring further treatment by APC (recurrence rate, 68.2%). Seven patients died during the follow-up period, including two cases with bleeding-related deaths. In the 12 patients who received EBL, endoscopies revealed the recurrence of GAVE in one patient requiring further treatment by EBL (recurrence rate, 8.3%). Two patients died during the follow-up period, neither were bleeding-related deaths.
The results suggest that GAVE is related to severe liver damage and portal hypertension. APC has a high recurrence rate of GAVE in the medium term after treatment. EBL may be useful as a treatment for GAVE.

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    • "They showed that endoscopic band ligation was superior to APC with a higher rate of haemostasis, a decrease in the transfusion requirement, and an increase in haemoglobin levels. Two recent retrospective studies have confirmed the safety and effectiveness of this procedure [77] [78]. More randomised controlled trials are needed to confirm these results, but endoscopic band ligation is already considered an effective alternative therapy for bleeding GAVE. "
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    ABSTRACT: Background: Gastric antral vascular ectasia (GAVE) is characterized by diffuse vasodilation mainly affecting the antrum and causes gastrointestinal hemorrhage. Argon plasma coagulation (APC) provides rapid coagulation of a wide region, and thus appears to be more useful than conventional methods for the treatment of extensive lesions with superficial oozing bleeding, such as GAVE. In this study, we evaluated the use of APC for GAVE. Methods: The study subjects were 22 patients with GAVE (10 men and 12 women, mean age 65.8 years, diffuse type (n = 19) and watermelon type (n = 3)) who developed gastrointestinal hemorrhage (melena, fall in hemoglobin (Hb, by ≥ 2.0 g/dL), or endoscopy-confirmed bleeding) and treated with APC. Endoscopic treatment was applied weekly, and considered successful if all detectable GAVE lesions were eradicated and the Hb stabilized without further transfusion. Clinical outcome was assessed. Results: The median total number of treatment sessions was four (range: 2–9 times), and the median observation period was 23.5 months. The cumulative recurrence-free rate was 49.7% after 1 year, 35.5% after 2 years, and 35.5% after 3 years. The survival rates after treatment were 94.4, 75.8 and 64.9% at 1, 2, and 3 years, respectively. No complications of APC were observed. Conclusion: APC appears to be effective for temporary control of hemorrhage and anemia due to GAVE, but is not always effective over the long term. For proper management of GAVE, drug therapy, blood transfusion and control of the underlying disease are necessary in addition to achieving hemostasis temporarily by APC.
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    ABSTRACT: Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are two distinct gastric mucosal lesions that may cause acute and/or chronic upper gastrointestinal hemorrhage in patients with cirrhosis. Whereas PHG is associated with portal hypertension, GAVE may present in patients without portal hypertension or liver disease. Diagnosis is made upon visualization of the characteristic lesions with upper gastrointestinal endoscopy, although the differential may be difficult at times. PHG is characterized endoscopically by a mosaic pattern with or without red signs and a proximal distribution. PHG mainly causes chronic blood loss and anemia in patients with cirrhosis but also can cause acute hemorrhage. First-line therapy for chronic hemorrhage from PHG is a nonselective beta-blocker (propranolol or nadolol) and iron supplementation. If bleeding/anemia are not controlled with these measures and the patient is transfusion-dependent, shunt therapy (transjugular intrahepatic portosystemic shunt or shunt surgery) should be considered. Management of acute bleeding from PHG, an infrequent event, should be accomplished with a vasoactive drug, somatostatin (or its analogues) or terlipressin. If bleeding responds, the patient must be switched to a nonselective beta-blocker. Shunt therapy should be considered in patients who rebleed or continue to bleed despite adequate beta-blocker therapy. GAVE is less common than PHG. It is characterized by red spots without a background mosaic pattern, typically in the gastric antrum. When lesions have a linear distribution, the lesion is called "watermelon stomach." GAVE is a cause of chronic gastrointestinal bleeding and anemia in patients with cirrhosis. If lesions are localized, first-line therapy is argon plasma coagulation. In more diffuse lesions, therapy with argon plasma coagulation is more complicated. Preliminary data suggest that cryotherapy may be a reasonable option for diffuse GAVE lesions. Neither beta-blockers nor TIPS reduces the bleeding risk in patients with GAVE and thus should not be used in this setting.
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