Kudaravalli Pujitha, Saleem Sheikh A, Mandru Rachana, Rawlins Sekou
Department of Internal Medicine, Upstate Medical University, 750 E. Adams Street, Syracuse, NY 13210, USA.
Department of Gastroenterology, Upstate Medical University, 750 E. Adams Street, Syracuse, NY 13210, USA.
Case Rep Med. 2019 Sep 29;2019:1342368. doi: 10.1155/2019/1342368. eCollection 2019.
Gastric antral vascular ectasia (GAVE) is the underlying cause for 4% of nonvariceal upper GI bleeding. Nodular GAVE and gastric hyperplastic polyps have similar appearance on upper GI endoscopy (EGD) as well as histology, which could delay specific targeted therapy. We herein, through this case, would like to highlight that high clinical suspicion is required to diagnose nodular GAVE.
A 70-year-old male with a past medical history significant for coronary artery disease s/p drug-eluting stent placement on Plavix, coronary artery bypass grafting, mechanical aortic valve replacement on warfarin, and iron deficiency anemia on replacement was admitted for the evaluation of fatigue and melena for a month. Physical examination was positive for black stool. The only significant lab was a drop in hemoglobin/hematocrit (Hg/dl/H%) of 10/32 to 4/12.5. Fibrosure was sought which suggested that the patient had an F4 cirrhosis. Endoscopy showed nodules in the gastric antrum which were presumptively treated as GAVE with argon plasma coagulation (APC). Surgical pathology showed reactive gastropathy and gastric polyps. Review of the past histology suggested that because of the overlap in the histopathological features of hyperplastic polyps and GAVE, they were misinterpreted as hyperplastic polyp rather than nodular GAVE.
GAVE can be classified endoscopically as punctate, striped, nodular, or polypoidal form. The light microscopic findings considered specific to GAVE are vascular hyperplasia, mucosal vascular ectasia, intravascular fibrin thrombi, and fibromuscular hyperplasia. However, these findings do not differentiate GAVE from hyperplastic gastric polyp. The first line of treatment for GAVE is endoscopic ablation with Nd:YAG laser or argon plasma coagulation. Response to therapy was seen with a mean of 2.6 treatment sessions. There is not a lot of evidence supportive of pharmacological treatment of GAVE with estrogen-progesterone, tranexamic acid, and thalidomide. Serial endoscopic band ligation as well as detachable snares in the management of nodular GAVE refractory to argon plasma coagulation has also been tried.
Oftentimes, there is a delay in the diagnosis and treatment of nodular GAVE as the histopathological appearance could be similar to gastric polyps. The diagnosis of GAVE especially nodular GAVE requires a high level of clinical suspicion. Misdiagnosis of nodular GAVE can delay targeted therapy and have fatal outcomes.
胃窦血管扩张症（GAVE）是4%的非静脉曲张性上消化道出血的潜在病因。结节状GAVE和胃增生性息肉在上消化道内镜检查（EGD）以及组织学上有相似表现，这可能会延误特异性靶向治疗。我们在此通过这个病例强调，诊断结节状GAVE需要高度的临床怀疑。
一名70岁男性，既往有冠状动脉疾病病史，接受过药物洗脱支架置入（服用波立维）、冠状动脉搭桥术、机械主动脉瓣置换（服用华法林）以及缺铁性贫血替代治疗，因疲劳和黑便一个月入院评估。体格检查发现黑便阳性。唯一显著的实验室检查结果是血红蛋白/血细胞比容（Hg/dl/H%）从10/32降至4/12.5。进行了肝纤维化指标检测，提示患者为F4级肝硬化。内镜检查显示胃窦有结节，最初被当作GAVE用氩离子凝固术（APC）治疗。手术病理显示为反应性胃病和胃息肉。回顾既往组织学检查发现，由于增生性息肉和GAVE在组织病理学特征上有重叠，它们被误判为增生性息肉而非结节状GAVE。
GAVE在内镜下可分为点状、条纹状、结节状或息肉状。GAVE特有的光镜下表现为血管增生、黏膜血管扩张、血管内纤维蛋白血栓形成以及纤维肌增生。然而，这些表现并不能将GAVE与增生性胃息肉区分开来。GAVE的一线治疗是用钕钇铝石榴石激光或氩离子凝固术进行内镜下消融。平均2.6次治疗后可见治疗反应。关于用雌激素 - 孕激素、氨甲环酸和沙利度胺对GAVE进行药物治疗，支持证据不多。对于氩离子凝固术难治的结节状GAVE，也尝试过连续内镜下套扎以及可分离圈套器治疗。
通常，结节状GAVE的诊断和治疗会出现延误，因为其组织病理学表现可能与胃息肉相似。GAVE尤其是结节状GAVE的诊断需要高度的临床怀疑。结节状GAVE的误诊会延误靶向治疗并导致致命后果。
