Stomach

Other nonneoplastic

Gastric antral vascular ectasia



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PubMed Search: Gastric antral vascular ectasia

Hunter Monroe, B.S.
Tony El Jabbour, M.D.
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Cite this page: Monroe H, El Jabbour T. Gastric antral vascular ectasia. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/stomachantralvascularect.html. Accessed February 6th, 2023.
Definition / general
  • Antral vascular malformation with dilation of superficial mucosal and submucosal blood vessels, often with associated fibrin microthrombi
Essential features
  • Accounts for up to 4% of nonvariceal gastrointestinal bleeding, usually chronic with associated iron deficiency
  • Histologically characterized by variable mucosal and submucosal vessel ectasia, fibrin thrombi, reactive foveolar changes and fibromuscular hyperplasia
  • May present clinically as striped (watermelon stomach) form in younger males with cirrhosis of the liver, diffuse punctate (honeycomb stomach) form in older females with autoimmune disorders or nodular form
  • Endoscopic ablative therapy such as argon plasma coagulation (APC) is first line treatment; antrectomy only if severe and refractory (due to high postoperative mortality rate)
  • Primary differential includes portal hypertensive gastropathy, which may present with vascular ectasia but lacks fibrin thrombi
Terminology
  • Linear striped type referred to as watermelon stomach
  • Diffuse punctate type called honeycomb stomach
  • Originally described as erosive gastritis with venocapillary ectasia by Reider in 1953
ICD coding
  • ICD-10:
    • K31.811 - angiodysplasia of stomach and duodenum with bleeding
    • K31.819 - angiodysplasia of stomach and duodenum without bleeding
  • ICD-11: DA43.4 - diffuse vascular ectasia of stomach
Epidemiology
Sites
  • Gastric antrum
  • Rare extra-antral sites include gastric cardia, duodenum, jejunum and rectum (Gut 1993;34:558)
Pathophysiology
  • Pathophysiology is unknown, though several theories have been proposed:
    • Chronic liver dysfunction leads to increased blood concentrations of vasodilatory hormones and metabolites such as gastrin, VIP and PGE2 (World J Gastrointest Endosc 2013;5:6)
    • Mechanical stress from gastric peristalsis induces prolapse, antral mucosal trauma and vessel obstruction, resulting in vascular ectasia and fibromuscular hyperplasia
    • Autoimmune antibodies react with proteins that are present in the gastric mucosal and submucosal vessels
Etiology
  • Unknown
Clinical features
Diagnosis
  • Esophagogastroduodenoscopy (EGD) is gold standard for endoscopy (Semin Arthritis Rheum 2020;50:938)
  • Antral biopsy may be useful to rule out portal hypertensive gastropathy if comorbid cirrhosis
    • Biopsy may not exclude GAVE, as lesions may be focal
  • Fecal occult blood tests
Laboratory
  • Anemia
  • Iron deficiency
  • Anti-RNA polymerase III (RNAPIII) antibodies present in up to 71% of GAVE patients with systemic sclerosis (Semin Arthritis Rheum 2020;50:938)
    • Concomitant GAVE and anti-RNAPIII is strongly correlated with scleroderma renal crisis
Radiology description
Prognostic factors
  • Exact mortality is unknown but appears to be low (Gastroenterology Res 2021;14:104)
  • Recurrence rate is ~40%
  • Factors associated with poorer prognosis (Gastroenterology Res 2021;14:104):
    • Hemorrhage associated with higher mortality
    • Mortality increases with number of comorbidities
    • Hispanic status may be associated with poorer prognosis
    • Higher mortality rate if refractory to endoscopic ablation
Case reports
Treatment
Clinical images

Contributed by Tony El Jabbour, M.D.

Diffuse punctate pattern



Images hosted on other servers:

Striped pattern

Diffuse punctate pattern

Nodular pattern

Microscopic (histologic) description
  • Dilated mucosal capillaries
  • Reactive foveolar changes
  • Intravascular fibrin thrombi
  • Fibromuscular hyperplasia of lamina propria
  • Fibrohyalinosis (perivascular hyalinization)
Microscopic (histologic) images

Contributed by Hwajeong (Jenny) Lee, M.D.

Antrum with reactive changes

Fibrin thrombus

Videos

Histopathology of gastric antral vascular ectasia

Sample pathology report
  • Antrum, biopsy:
    • Gastric antral mucosa with vascular dilation in the lamina propria with extravasation of red blood cells and rare fibrin thrombi (see comment)
    • Comment: These features could be seen in gastric antral vascular ectasia (GAVE) and portal hypertensive gastropathy. Correlation with the clinical history and endoscopic aspect of the mucosa at the site of the biopsy are necessary to establish the diagnosis.
Differential diagnosis
  • Portal hypertensive gastropathy (World J Gastrointest Endosc 2013;5:6):
    • May present with vascular ectasia
    • Affects gastric fundus and corpus
    • Endoscopically presents with mosaic red point lesions, cherry red spots or black-brown spots
    • Lacks fibrin microthrombi
    • Responds to portal hypertensive therapies (beta blockers, portocaval shunt, etc.)
  • Telangiectasia:
  • Reactive gastropathy:
    • Appears with similar, if identical, reactive foveolar changes
    • May contain mucosal capillary ectasia
    • Typically lacks fibrin microthrombi
  • Hyperplastic polyps:
    • May mimic nodular GAVE on endoscopy
    • Contains elongated, cystically dilated foveolar epithelium
    • More prominent inflammation in lamina propria
Board review style question #1

The microphotograph above demonstrates a section obtained from a biopsy of the gastric antrum in a 71 year old woman presenting with chronic melena and iron deficiency anemia. Which of the following is true of this patient's disease?

  1. Antrectomy is associated with the most favorable postoperative outcomes
  2. Endoscopic ablative treatments such as argon plasma coagulation are first line
  3. It typically presents as acute heavy upper gastrointestinal bleeding
  4. On endoscopy, it usually presents as parallel red stripes in patients with comorbid cirrhosis
Board review style answer #1
B. Endoscopic ablative treatments such as argon plasma coagulation are first line

Comment Here

Reference: Gastric antral vascular ectasia
Board review style question #2
Which of the following is true of both gastric antral vascular ectasia (GAVE) and portal hypertensive gastropathy?

  1. Dilated mucosal capillaries are routinely present on histology
  2. Endoscopically presents as mosaic red point lesions and black-brown spots
  3. Histologically characterized by intravascular fibrin thrombi
  4. Responsive to antihypertensive therapies such as beta blockers
Board review style answer #2
A. Dilated mucosal capillaries are routinely present on histology

Comment Here

Reference: Gastric antral vascular ectasia
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