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Presented by Elizabeth Montgomery, M.D. and prepared by Todd Sheridan, M.D.
Case 1: This patient had gastrointestinal bleeding which ultimately required resection of the antrum.
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1. Question
Week 253: Case 1
This patient had gastrointestinal bleeding which ultimately required resection of the antrum. The images are of the gastric antrum from a resection specimen.images/1.16.06.EAMcase1a.jpg
images/1.16.06.EAMcase1b.jpg
images/1.16.06.EAMcase1c.jpg
images/1.16.06.EAMcase1d.jpg
images/1.16.06.EAMcase1e.jpgCorrect
Answer: Gastric antral vascular ecstasia (“watermelon” stomach)
Histology: none provided
Discussion: “Watermelon stomach” was first described by Jabbari in 1984 and refers to an endoscopic appearance. In this condition, longitudinal antral folds have visible reddened vessels radiating from the pylorus in a distribution resembling a watermelon rind. Patients present with iron deficiency secondary to chronic gastric bleeding. The typical patient is an elderly woman with achlorohydria, chronic liver disease, CREST syndrome, or lymphoma. Some cases are associated with scleroderma. In some cases the endoscopic appearance is not prototypic but instead consists of diffuse gastric erythema. The etiology is not well-known, but it is probably an acquired lesion. Some patients have antral prolapse.
Histologic examination discloses features that reflect a mucosal prolapse component: there is foveolar hyperplasia, dilated mucosal capillaries, focal thrombi, and fibromuscular hypertrophy. Similar features may be seen in patients who have portal hypertension, but the dilated capillaries in portal hypertension lack fibrin thrombi (though patients with “watermelon stomach” may also have portal hypertension). Treatment of “watermelon stomach” often entails mucosal ablation since the patients have uncontrolled blood loss. Endoscopic therapy, including contact and non-contact thermal ablations of the ecstatic vascular lesions, is the mainstay of conservative therapy. However, many patients fail endoscopic therapy and develop recurrent acute and chronic GI bleeding episodes. Surgical resection may be the only reliable method for achieving a cure and eliminating transfusion dependency. Traditionally, surgery was used only as a last resort after patients failed prolonged medical and/or endoscopic therapy. However, based on the experience garnered from the literature some authors have recommend a more aggressive surgical approach in patients who fail a short trial of endoluminal therapy.
Reference(s):
– Jabbari M, Cherry R, Lough JO, Daly DS, Kinnear DG, Goresky CA. Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology. 1984;87(5):1165-70.
– Manolios N, Eliades C, Duncombe V, Spencer D. Scleroderma and watermelon stomach. J Rheumatol. 1996;23(4):776-8.
– Gilliam JH, 3rd, Geisinger KR, Wu WC, Weidner N, Richter JE. Endoscopic biopsy is diagnostic in gastric antral vascular ectasia. The “watermelon stomach”. Dig Dis Sci. 1989;34(6):885-8.
– Dulai GS, Jensen DM, Kovacs TO, Gralnek IM, Jutabha R. Endoscopic treatment outcomes in watermelon stomach patients with and without portal hypertension. Endoscopy. 2004;36(1):68-72.
– Novitsky YW, Kercher KW, Czerniach DR, Litwin DE. Watermelon stomach: pathophysiology, diagnosis, and management. J Gastrointest Surg. 2003;7(5):652-61.Incorrect
Answer: Gastric antral vascular ecstasia (“watermelon” stomach)
Histology: none provided
Discussion: “Watermelon stomach” was first described by Jabbari in 1984 and refers to an endoscopic appearance. In this condition, longitudinal antral folds have visible reddened vessels radiating from the pylorus in a distribution resembling a watermelon rind. Patients present with iron deficiency secondary to chronic gastric bleeding. The typical patient is an elderly woman with achlorohydria, chronic liver disease, CREST syndrome, or lymphoma. Some cases are associated with scleroderma. In some cases the endoscopic appearance is not prototypic but instead consists of diffuse gastric erythema. The etiology is not well-known, but it is probably an acquired lesion. Some patients have antral prolapse.
Histologic examination discloses features that reflect a mucosal prolapse component: there is foveolar hyperplasia, dilated mucosal capillaries, focal thrombi, and fibromuscular hypertrophy. Similar features may be seen in patients who have portal hypertension, but the dilated capillaries in portal hypertension lack fibrin thrombi (though patients with “watermelon stomach” may also have portal hypertension). Treatment of “watermelon stomach” often entails mucosal ablation since the patients have uncontrolled blood loss. Endoscopic therapy, including contact and non-contact thermal ablations of the ecstatic vascular lesions, is the mainstay of conservative therapy. However, many patients fail endoscopic therapy and develop recurrent acute and chronic GI bleeding episodes. Surgical resection may be the only reliable method for achieving a cure and eliminating transfusion dependency. Traditionally, surgery was used only as a last resort after patients failed prolonged medical and/or endoscopic therapy. However, based on the experience garnered from the literature some authors have recommend a more aggressive surgical approach in patients who fail a short trial of endoluminal therapy.
Reference(s):
– Jabbari M, Cherry R, Lough JO, Daly DS, Kinnear DG, Goresky CA. Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology. 1984;87(5):1165-70.
– Manolios N, Eliades C, Duncombe V, Spencer D. Scleroderma and watermelon stomach. J Rheumatol. 1996;23(4):776-8.
– Gilliam JH, 3rd, Geisinger KR, Wu WC, Weidner N, Richter JE. Endoscopic biopsy is diagnostic in gastric antral vascular ectasia. The “watermelon stomach”. Dig Dis Sci. 1989;34(6):885-8.
– Dulai GS, Jensen DM, Kovacs TO, Gralnek IM, Jutabha R. Endoscopic treatment outcomes in watermelon stomach patients with and without portal hypertension. Endoscopy. 2004;36(1):68-72.
– Novitsky YW, Kercher KW, Czerniach DR, Litwin DE. Watermelon stomach: pathophysiology, diagnosis, and management. J Gastrointest Surg. 2003;7(5):652-61.
