Gastric antral vascular ectasia (GAVE) pathohistology and clinical implications

Abstract

AIM: Gastric antral vascular ectasia (GAVE) is disorder not so common by occurrence with set of microscopic and/or endoscopic appearances of gastric mucosa. Although etiology and associations are not fully understood, pathogenesis of GAVE could represent prolapse of mobile mucosa through pylorus. Most cases are idiopathic while reminders are secondary to cirrhosis or system sclerosis with various ambiguous points considering etiology, course and treatment. We aimed to analyze upper gastric endoscopic biopsies for GAVE, with respect to pathohistological and clinical particularities.
METHODS: A retrospective cross sectional study of 3100 consecutive upper gastrointestinal endoscopies routinely performed at Department of Gastroenterology in time period from January 1st till December 31st 2008. Diagnose was established according to set of typical histological findings with standard hematoxylin and eosine staining and immunohistochemistry (CD34) regarding inconclusive specimens.
RESULTS: There were found 2 cases of GAVE (0.065%) presenting as gastric antral polyps with spindle cell proliferation, fibrohyalinosis, vascular ectasia and thrombus (Figure 1 and 2). Patients, female 55 years of age and male 53, both without indicative co-morbidities, idiopathic cases represented as incidental findings in diagnostic workup. The laboratory diagnostic parameters were unremarkable. Changes in one additional sample from fundic part of the stomach were also inconclusive alike to GAVE, clinically diagnosed as moderate chronic gastritis. Histology was almost the same as two previously described but localization of the lesion and lack of spindle cell proliferation, fibrohyalinosis with mild ectasia, originated probably due to portal hypertensive gastropathy (Figure 3).
DISCUSSION: Female patient in our study presented with chronic gastritis complaints lasting for years, had multiple repeated endoscopic biopsies that were unspecific and was treated, like male patient, with PPI without satisfying response. Comparing clinical, histological and immunohistochemical findings the diagnoses were established.
CONCLUSION: Differentiation of GAVE to portal hypertensive gastropathy or appearance resembling malignance particularly in setting of cirrhosis is clinically important regarding presentation, diagnostic misleads, therapy, follow up and outcome. If endoscopic finding is not clear differential diagnoses could be ruled out by patohistology. There is a high rate of false negative diagnosis regarding GAVE, due to the fact that lesions are focal, thus negative biopsy result does not exclude diagnose. Misleading general symptoms can mimic any other disorder thus establishing late diagnosis to the patient eventually fatal in result.

Full text

GASTRIC ANTRAL VASCULAR ECTASIA (GAVE) PATHOHISTOLOGY AND CLINICAL
IMPLICATIONS
Pavić I 1, Demirović A1, Nikolić M2, Boban M2, Ljubičić N2, Baličević D1
1 University Department of Pathology “Ljudevit Jurak” University Hospital Sestre Milosrdnice,
Zagreb, Croatia
2 Department of Gastroenterology University Hospital Sestre Milosrdnice, Zagreb, Croatia
AIM: Gastric antral vascular ectasia (GAVE) is disorder not so common by occurrence with set of
microscopic and/or endoscopic appearances of gastric mucosa. Although etiology and associations
are not fully understood, pathogenesis of GAVE could represent prolapse of mobile mucosa through
pylorus. Most cases are idiopathic while reminders are secondary to cirrhosis or system sclerosis with
various ambiguous points considering etiology, course and treatment. We aimed to analyze upper
gastric endoscopic biopsies for GAVE, with respect to pathohistological and clinical particularities.
METHODS: A retrospective cross sectional study of 3100 consecutive upper gastrointestinal
endoscopies routinely performed at Department of Gastroenterology in time period from January 1st till
December 31st 2008. Diagnose was established according to set of typical histological findings with
standard hematoxylin and eosine staining and immunohistochemistry (CD34) regarding inconclusive
specimens.
RESULTS: There were found 2 cases of GAVE (0.065%) presenting as gastric antral polyps with
spindle cell proliferation, fibrohyalinosis, vascular ectasia and thrombus (Figure 1 and 2). Patients,
female 55 years of age and male 53, both without indicative co-morbidities, idiopathic cases
represented as incidental findings in diagnostic workup. The laboratory diagnostic parameters were
unremarkable. Changes in one additional sample from fundic part of the stomach were also
inconclusive alike to GAVE, clinically diagnosed as moderate chronic gastritis. Histology was almost
the same as two previously described but localization of the lesion and lack of spindle cell proliferation,
fibrohyalinosis with mild ectasia, originated probably due to portal hypertensive gastropathy (Figure 3).
DISCUSSION: Female patient in our study presented with chronic gastritis complaints lasting for
years, had multiple repeated endoscopic biopsies that were unspecific and was treated, like male
patient, with PPI without satisfying response. Comparing clinical, histological and
immunohistochemical findings the diagnoses were established.
CONCLUSION: Differentiation of GAVE to portal hypertensive gastropathy or appearance resembling
malignance particularly in setting of cirrhosis is clinically important regarding presentation, diagnostic
misleads, therapy, follow up and outcome. If endoscopic finding is not clear differential diagnoses
could be ruled out by patohistology. There is a high rate of false negative diagnosis regarding GAVE,
due to the fact that lesions are focal, thus negative biopsy result does not exclude diagnose.
Misleading general symptoms can mimic any other disorder thus establishing late diagnosis to the
patient eventually fatal in result.

Table1. A Comparison of Gastric Antral Vascular Ectasia (GAVE) and Portal Hypertensive
Gastropathy
Feature GAVE Portal Gastropathy
Sex Predominantly affects women More commonly affects men
Endoscopic lesions Appear as microvessels Diffuse erythema
Localization Fundus or corpus Antrum
Anemia and hemorrhage High incidence Low incidence
Vascular spindle cell
proliferation
Yes No
Presence of thrombosis Yes/ about 50% specimens No
Presence of fibrohyalinosis Yes No
Presence of cirrhosis 30% of patients Always
Degree of ectasia Marked ectasia Mild-moderate ectasia
Therapy Antrectomy and gastrectomy,Laser
coagulation, Oestrogen and
progesterone, Tranexamic acid,
Octreotide
β-blockers, surgical shunt
procedures

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