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ABSTRACT: Antral vascular ectasia ("watermelon stomach") has recently been defined and characterized. This condition may be a source of significant bleeding from the stomach. Although steroids have been useful in some patients, antrectomy has been advocated as definitive therapy. We have treated 12 patients who were bleeding from this lesion with the Olympus HeatProbe Unit and have eliminated further hemorrhage. All presented with gastrointestinal bleeding, iron-deficiency anemia, and compatible antral biopsies. Using the large probe, vascular streaks were treated until the endoscopic appearance returned to normal (average four treatment sessions). No further bleeding was evident from the antral vascular ectasia over an average follow-up period of 20.9 months. Eight of 10 patients who had required transfusion prior to therapy no longer needed transfusion, but two received blood for other conditions. We conclude that antral vascular ectasia can be successfully treated with the HeatProbe Unit and this should be the initial modality of therapy for this condition.Gastrointestinal Endoscopy 07/1989; 35(4):324-8. · 5.21 Impact Factor
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ABSTRACT: The effect of Yag laser photocoagulation on the course of bleeding of gastrointestinal vascular malformations was studied in 59 patients, with a total of 482 lesions. The lesions were located in the upper gastrointestinal tract alone in 25 patients, in the lower tract alone in 31 patients and in both the lower and the upper gastrointestinal tract in three patients. In the month before laser therapy the number of bleeding episodes averaged 1.09 +/- 0.6 (SD) per patient (n = 57) and the transfusion requirements 2.4 +/- 2.6 red blood cells units per patient, while in the month after treatment the bleeding incidence averaged 0.16 +/- 0.5 and the transfusion requirements 0.21 +/- 0.8 (both p less than 0.001). Long term results were analysed considering for each patient an equally long pretreatment and follow up period. After a mean follow up period of 11.5 months (1-48 months), 17 of the 57 patients available for follow up rebled. The reduction of the bleeding rate was statistically significant at one, six, 12, and 18 months of follow up, while transfusion rate was significantly decreased at one, six, and 12 months. The results were disappointing in patients with Osler-Weber-Rendu (n = 4) and in patients with angiomas associated with Von Willebrand's disease (n = 3), who all rebled. In angiodysplasia the treatment was successful in 82% of the 49 patients. The more numerous the lesions, the less effective the reduction in bleeding rate by laser treatment was. Histological studies showed that the haemostatic effect of Yag laser photocoagulation was obtained by destruction of the lesion. Rebleeding was due to lesions missed at the first treatment, incompletely treated lesions and recurrence of new lesions. In two patients a free caecal perforation necessitated a right hemicolectomy. In both patients numerous or very large lesions had been treated in the caecum.Gut 07/1985; 26(6):586-93. · 10.73 Impact Factor
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ABSTRACT: Fifty-six patients who presented with non-steroidal anti-inflammatory drug-associated duodenal ulcers received maintenance treatment with ranitidine. Forty-eight of these patients stopped treatment with non-steroidal anti-inflammatory drugs. The cumulative symptomatic remission at the end of 5 years of maintenance treatment was 97.7%. While half the patients had presented with haemorrhage from the ulcer, only one patient bled during maintenance treatment, giving a cumulative risk of 2.3% in 5 years of maintenance treatment. We conclude that maintenance treatment with ranitidine effectively and safely keeps patients with non-steroidal anti-inflammatory drug-associated ulcers symptom- and risk-free.Alimentary Pharmacology & Therapeutics 11/1989; 3(5):499-503. · 4.55 Impact Factor
pared with non-NSAID ulcers? The results of
our study seem to indicate that this aspect of
clinical trials would have to be addressed in
future publications on ulcer treatment.
RONALD E GREENBERG
LongIslandJ3ewish Medical Center,
270-05 76th Avenue,
New Hyde Park,
New York 11042
1 Bank S, Greenberg RE, Magier D. The efficacy and
tolerability of famotidine and ranitidine on the
healing of active duodenal ulcer and during six-
month maintenance treatment, with special
reference to NSAID/aspirin-related ulcers. Clin
Ther 1991; 13: 304-18.
NSAID associated gastric and duodenal ulcers
while taking a histamine receptor antagonist
strictly comparable to those published recently
on behalf of a United Kingdom multicentre
study group. It seems probable from their
NSAID associated ulcers even more readily
than non-NSAID associated ulcers providing
the NSAID is stopped. A similar comparison
cannot be made from our study because all
patients were taking NSAIDs at the time of
referral. Bank et al ask whether NSAID
associated ulcers heal successfully with placebo
treatment if the NSAID is stopped. Neither
their or our study answers this question. With
respect to gastric ulcer, however, Loludice
et al' found that with antacid alone only 25% of
patients healed within six weeks despite having
stopped NSAIDs compared with 66% with
antacids plus cimetidine.
Bianchi Porro and Pace2 also showed that
severe gastric lesions after NSAID withdrawal
healed within four weeks in 50% ofpatients on
placebo compared with 83% on ranitidine. By
contrast, ofthose who continued with NSAIDs
and took placebo, only 25% had healed lesions.
Comparable information about the behaviour
ofNSAID associated duodenal ulcer seems not
to be available.
The better performance of HRA mainten-
ance treatment in NSAID associated duodenal
ulcer compared with non-NSAID associated
ulcer reported by Bank et al agrees with the
findings ofPenston and Wormsley.' Neverthe-
less, responsiveness to maintenance treatment
seems not to be accompanied by a low natural
relapse rate because seven of 14 patients in
Penston and Wormsley's study had recurrent
when maintenance was omitted.
It is clear that future studies should take into
account these apparent differences between the
natural history of NSAID associated and
'idiopathic' ulcers, but retrospective analysis of
past work is likely to be oflimited value as most
ulcer healing and maintenance studies have
specifically excluded patients on NSAID treat-
Peptic ulcer remains a multifactorial disease
but despite this these studies show that in the
great majority of cases, regardless of aetiology,
control is achievable with HRA treatment.
et al report healing rates for
that an H,RA
M LANCASTER SMITH
Queen Mary's Hospital,
Sidcup, KentDA 14 6LT
1 Loludice TA, Saleem T, Lang JA. Cimetidine in
the treatment of gastric
ulcer; induced by
steroidal and non-steroidal anti-inflammatory
agents. AmJ Gastroenterol 1981; 75: 104-10.
2 Bianchi Porro G, Pace F. Ulcerogenic drugs and
upper gastrointestinal bleeding. In: Bircher J,
ed. Bailliere's clinical gastroenterology. Vol 2, Part
2. London: Bailliere-Tindall, 1988: 309-27.
3 Penston JG, Wormsley KG. Ranitidine mainte-
inflammatory drug-induced duodenal ulceration.
Alimentary Pharmacology and Therapeutics 1989;
Case ofwatermelon stomach successfully
treated by heat probe electrocoagulation
SIR,-We read with interest the report by Tsai
et al (Gut 1991; 32: 93-4) of a patient whose
gastric antral vascular ectasia was treated by
laser photocoagulation. We have a similar case
of a 77 year old woman to whom we applied
heat probe electrocoagulation (Olympus Heat
Probe Unit) with an equally satisfactory result.
The patient had a long history of iron
deficiency anaemia, thought to be due to severe
antral gastritis, which despite continuous oral
and intravenous administration ofiron was not
under control. Several transfusions (at a rate of
1-4 units of blood per month) had been
required since the beginning of 1990. In July
when she collapsed with a haemoglobin con-
centration of54 g/l, a diagnosis of'watermelon
stomach' was made endoscopically and con-
firmed histologically. There was no evidence of
liver disease or portal hypertension. Two
sessions of heat probe treatment were carried
out applying 100 deliveries of 10 joules each.
Subsequently there has been no need for
further transfusion and the patient's haemo-
globin remains above 100 g/l. However, there
has been no change in the endoscopic picture.
Our patient had a history of coronary heart
disease which is suggested' as a predisposing
factor (as are liver cirrhosis and portal hyper-
tension) to the formation of mucosal vascular
malformations. Bipolar2 and heat probe3 elec-
trocoagulation have been reported to be as
effective as the more expensive laser photo-
coagulation for treatment of gastric antral
vascular ectasia, and our experience confirms
JOHN R BENNETT
Gastro Intestinal Unit,
Kingston upon HullHU3 27Z
Correspondence to: Dr Kamberoglou.
1 Rutgeerts P, Van Gompel F, Geboes K, Vantrap-
pen G, Broeckaert L, Coremans G. Long term
results oftreatment ofvascular malformations of
the gastrointestinal tract by Neodymium Yag
laser photocoagulation. Gut 1985; 25: 586-93.
2 Binmoeller KF, Katon RM. Bipolar electro-
coagulation for watermelon stomach. Gastrointest
Endosc 1990; 36: 399-402.
3 Petrini JL, Johnston JH. Heat probe treatment for
antral vascular ectasia. Gastroiniest Endosc 1989;
SIR,-I read the letter of Kamberoglou et al
with interest. Their patient had many features
similar to the case we reported, with similar
pretreatment transfusion requirements and
coagulation has been used successfully
treatment ofbleeding duodenal ulcers' and also
has the advantage of being cost effective
compared with the Nd:YAG
coagulation. I am, however, a little concerned
inthe control of bleeding
in the watermelon stomach. Collateral thermal
damage to gastric mucosa is likely to be greater.
It would be oflittle consequence ifthe vascular
ectasia occupied only a small area of the
antrum. However, the vascular lesions may be
extensive.2 The safety aspectofthermocoagula-
tion of large areas of the stomach with a heat
probe has not been addressed. The authors also
admit that there was no visible resolution ofthe
lesions endoscopically. In the laser treated
patient, however, the endoscopic appearances
improved, suggesting regression of the vascu-
lar abnormality which may have some bearing
on rates of recurrence of bleeding in treated
While heat probe thermocoagulation repre-
sents a cheap and attractive treatment for the
smaller lesions ofwatermelon stomach, I think
that treatment of the more extensive lesions is
likely to be better with laser photocoagulation.
H H TSAI
1 Papp JP. Heat probe versus BICAP probe in the
treatment ofupper gastrointestinal bleeding. Am
J Gastroenterol 1987; 82: 619-21.
2 Jabbari M, Cherry R, Lough JO, Daly DS,
Kinnear DG, Goresky CA. Gastric antral vascu-
lar ectasia: the watermelon stomach. Gastro-
enterology 1984; 87: 1165-70.
Sir Francis AveryJones BSG Research
Applications are invited by the Education
Committee of the British Society of Gastro-
enterology, who will recommend to Council
the recipient of the 1992 award. Applications
(1) A manuscript (2 A4 pages only) des-
cribing the work conducted.
(2) A bibliography ofrelevant personal pub-
(3) An outline ofthe proposed content ofthe
lecture, including title.
(4) A written statement confirming that all
or a substantial part of the work has been
personally conducted in the United Kingdom
The award consists of a medal and a £100
prize. Entrants must be 40 years of age or less
on 31 December 1992 but need not be a
member of the BSG. The recipient will be
required to deliver a 40 minute lecture at the
SpringMeetingofthe Society in 1992. Applica-
tions (15 copies) should be made to: The
Honorary Secretary, BSG, 3 St Andrew's
Place, Regent's Park, London NW1 4LB by
1 December 1991.
Postgraduate Gastroenterology Course
A Postgraduate Gastroenterology Course will
take place on 5-8 January 1992 in Oxford.
Further information is available from Dr D P
Jewell, Radcliffe Infirmary, Oxford 0X2 6HE.
Tel: 0865 224829.