Refractory gastric antral vascular ectasia: a new endoscopic approach

Gastric antral vascular ectasia (GAVE) is an uncommon disorder observed in patients with liver cirrhosis, causing upper gastro-intestinal haemorrhage. GAVE is diagnosed through esophagogastroduodenoscopy and is characterized by the presence of visible columns of red tortuous enlarged vessels along the longitudinal folds of the antrum (i.e., so-called watermelon stomach). Pharmacological, endoscopic and surgical approaches have been proposed for the treatment of GAVE. Endoscopy represents the gold standard for GAVE treatment. The most widely used endoscopic approach is represented by Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser. Argon plasma coagulation (APC) has been proven to be more efficient in terms of costs and complication rates than and equally effective as Nd:YAG. Other endoscopic procedures proposed for this treatment are banding ligature (EBL) and sclerotherapy with Polidocanol. Refractory GAVE represents a therapeutic challenge because it may cause persistent anemia, often leading to repeated blood transfusions due to the inefficacy of pharmacological and endoscopic therapeutic approaches. Endoscopic band ligation (EBL) has been shown to be superior to APC in the treatment of refractory GAVE. Surgical antrectomy by Billroth I anastomosis can be considered in selected cases. In this study, we report a successful endoscopic treatment of refractory GAVE by using a combination of submucosal injection of 1% Polidocanol at the four antral quadrants and subsequent application of APC on the visible antral lesions in two patients.