Comparison of argon plasma coagulation in management of upper gastrointestinal angiodysplasia and gastric antral vascular ectasia hemorrhage

BMC Gastroenterology

Seng-Kee Chuah²  King-Wah Chiu²  Wei-Chen Tai²  Ming-Luen Hu²  William Tam¹  Keng-Liang Wu²  Lung-Sheng Lu²  Yi-Chun Chiu² 

[1] Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia;Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, Niao-Sung District, Kaohsiung City, 833, Taiwan

关键词: Gastric antral vascular ectasia;    Angiodysplasia;    Endoscopic argon plasma coagulation;   

Others  :  1113042
DOI  :  10.1186/1471-230X-12-67

 received in 2011-11-17, accepted in 2012-06-09,  发布年份 2012

【 摘 要 】

Background

Vascular ectasias, including gastric antral vascular ectasia (GAVE) and angiodysplasia, are increasingly recognized as important sources of gastrointestinal bleeding. This study investigated and compared the efficacies and outcomes of treatment of upper gastrointestinal (UGI) angiodysplasia and GAVE hemorrhage by endoscopic argon plasma coagulation (APC).

Methods

From January 2006 to December 2009, 46 patients diagnosed with upper GI bleeding caused by angiodysplasia or GAVE at a tertiary hospital were recruited into this study. They included 26 males and 20 females with an average age of 65.6 years (range, 45–90 years). All patients underwent APC for hemostasis during an endoscopic procedure. Parameters such as underlying co-morbidities, number of endoscopic treatment sessions, recurrent bleeding, and clinical outcomes during follow-up were analyzed.

Results

The 46 patients with UGI vascular ectasia hemorrhage included 27 patients with angiodysplasia and 19 with GAVE. The patients with angiodysplasia were older than those with GAVE (71.6 ± 10.2 years versus 61.8 ± 11.9 years, P = 0.005). More GAVE patients than angiodysplasia patients had co-existing liver cirrhosis (63.2% versus 25.9%, P = 0.012). The patients with GAVE had a higher rate of recurrent bleeding (78.9% versus 7.4%, P < 0.001) and required more treatment sessions to achieve complete hemostasis (2.4 ± 1.4 versus 1.1 ± 0.1, P < 0.001) than those with angiodysplasia. Univariate analysis demonstrated that age greater than 60 years (odds ratio (OR) = 8.929, P = 0.003), GAVE (OR = 0.021, P < 0.001), and previous radiation therapy (OR = 11.667, P = 0.032) were associated with higher rates of recurrent bleeding. Further multivariate analysis revealed that GAVE was the only independent risk factor for recurrent bleeding after APC treatment (OR = 0.027, P < 0.001).

Conclusion

Endoscopic hemostasis with APC is a safe treatment modality for both angiodysplasia and vascular ectasia bleeding. The efficacy of APC treatment is greater for angiodysplasia than for vascular ectasia bleeding. GAVE patients have a higher recurrent bleeding rate and may require multiple treatment sessions for sustained hemostasis.

【 授权许可】

   
2012 Chiu et al.

【 参考文献 】

• [1]Pavey DA, Craig PI: Endoscopic therapy for upper gastrointestinal vascular ectasias. Gastrointest Endosc 2004, 59:233-238.
• [2]Clouse RE:  . In Textbook of Gastroenterology. 3rd edition. Edited by Yamada T. Lippincott Williams and Wilkins, Philadelphia; 1999:2564-2582.
• [3]Abedi M, Haber GB: Watermelon stomach. Gastroenterologist 1997, 5:179-184.
• [4]Gretz JE, Achem SR: The watermelon stomach: clinical presentation, diagnosis and treatment. Am J Gastroenterol 1998, 93:890-895.
• [5]Probst A, Scheubel R, Wienbeck M: Treatment of watermelon stomach (GAVE syndrome) by means of endoscopic argon plasma coagulation (APC): long-term outcome. Z Gastroenterol 2001, 39:447-452.
• [6]Markwick T, Kerlin P: Angiodysplasia of Upper gastrointestinal tract. Clinical spectrum in 41 patients. J Clin Gastroenterol 1986, 8:404-407.
• [7]Novitsky YW, Kercher KW, Czerniach DR, Litwin DE: Watermelon stomach: pathophysiology, diagnosis, and management. J Gastrointest Surg 2003, 7:652-661.
• [8]Boley SJ, Sammartano R, Adams A, Dibase A, Kleinhause S, Sprayregen S: On the nature of vascular ectasias of the colon. Gastroenterology 1977, 72:650-660.
• [9]Rogers BHG: Endoscopic diagnosis and therapy of mucosal vascular abnormalities of the gastrointestinal tract, occurring in elderly patients and associated with cardiac, vascular and pulmonary disease. Gastrointest Endosc 1980, 26:134-138.
• [10]Weaver GA, Alpern HD, Davis JS, Ramsey WH, Reichelderfer M: Gastrointestinal angiodysplasia associated with aortic valve disease: part of the spectrum of angiodysplasia of the gut. Gastroenterology 1979, 77:1-11.
• [11]Stefanidis I, Liakopoulos V, Kapsoritakis AN, Ioannidis I, Eleftheriadis T, Mertens PR, Winograd R, Vamvaka E, Psychos AK, Potamianos SP: Gastric antral ectasia (watermelon stomach) in patients with ESRD. Am J Kidney 2006, 47:77-82.
• [12]Brandt LJ: Gastric antral vascular ectasia: is there to be a consensus? Gastrointest Endosc 1996, 44:355.
• [13]Sargeant IR, Loizou LA, Rampton D, Tulloch M, Bown SG: Laser ablation of upper gastrointestinal vascular ectasia: long term results. Gut 1993, 34:470-475.
• [14]Ito M, Uchida Y, Kamano S, Kawabata H, Nishioka M: Clinical comparisons between two subsets of gastric antral vascular ectasia. Gastrointest Endosc 2001, 53:764-770.
• [15]Sebastian S, O’Morain CA, Buckley JM: Current therapeutic options for gastric antral vascular ectasia. Aliment Pharmacol Ther 2003, 18:157-165.
• [16]Chen CH, Lee CM, Lu SN, Changchien CS, Eng HL, Huang CM, Wang JH, Hung CH, Hu TH: Clinical significance of hepatitis B virus (HBV) genotypes and precore and core promoter mutations affecting HBV e antigen expression in Taiwan. J Clin Microbiol 2005, 43:600-606.
• [17]Liaw YF, Chu CM: Hepatitis B virus infection. Lancet 2009, 373:582-592.
• [18]Chen CH, Wang MH, Wang JH, Hung CH, Hu TH, Lee SC, Tung HD, Lee CM, Changchien CS, Chen PF, Hsu MC, Lu SN: Aflatoxin exposure and hepatitis C virus in advanced liver disease in a hepatitis C virus-endemic area in Taiwan. Am J Trop Med Hyg 2007, 77:747-752.
• [19]Dai CY, Ho CK, Huang JF, Hsieh MY, Hou NJ, Lin ZY, Chen SC, Hsieh MY, Wang LY, Chang WY, Yu ML, Chuang WL: Hepatitis C virus viremia and low platelet count: a study in a hepatitis B & C endemic area in Taiwan. J Hepatol 2010, 52:160-166.
• [20]Burak KW, Lee SS, Beck PP: Portal hypertensive gastropathy and gastric antral vascular ectasia (GAVE) syndrome. Gut 2001, 49:866-872.
• [21]Spahr L, Villeneuve JP, Dufresne MP, Tassé D, Bui B, Willems B, Fenyves D, Pomier-Layrargues G: Gastric antral vascular ectasia in cirrhotic patients: absence of relation with portal hypertension. Gut 1999, 44:739-742.
• [22]Primignani M, Carpinelli L, Preatoni P, Battaglia G, Carta A, Prada A, Cestari R, Angeli P, Gatta A, Rossi A, Spinzi G, De Franchis R: Natural history of portal hypertensive gastropathy in patients with liver cirrhosis. The New Italian Endoscopic Club for the study and treatment of esophageal varices (NIEC). Gastroenterology 2000, 119:181-187.
• [23]Potamiano S, Carter CR, Anderson JR: Endoscopic laser treatment of diffuse gastric antral vascular ectasia. Gut 1994, 35:461-463.
• [24]Liberski SM, McGarrity TJ, Hartle RJ, Varano V, Reynolds D: The watermelon stomach: long-term outcome in patients treated with Nd:YAG laser therapy. Gastrointest Endosc 1994, 40:584-587.
• [25]Gostout CJ, Viggiano TR, Ahlquist DA, Wang KK, Larson MV, Balm R: The clinical and endoscopic spectrum of the watermelon stomach. J Clin Gastroenterol 1992, 15:256-263.
• [26]Gostout CJ, Ahlquist DA, Radford CM, Viggiano TR, Bowyer BA, Balm RK: Endoscopic laser therapy for watermelon stomach. Gastroenterology 1989, 96:1462-1465.
• [27]Petrini JL, Johnston JH: Heat probe treatment for antral vascular ectasia. Gastrointest Endosc 1989, 35:324-328.
• [28]Fuccio L, Zagari RM, Serrani M, Eusebi LH, Grilli D, Cennamo V, Laterza L, Asioli S, Ceroni L, Bazzoli F: Endoscopic argon plasma coagulation for the treatment of gastric antral vascular ectasia-related bleeding in patients with liver cirrhosis. Digestion 2009, 79:143-150.
• [29]Herrera S, Bordas JM, Llach J, Ginès A, Pellisé M, Fernández-Esparrach G, Mondelo F, Mata A, Cárdenas A, Castells A: The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in patients admitted for GI hemorrhage. Gastrointest Endosc 2008, 68:440-446.
• [30]Olmos JA, Marcolongo M, Pogorelsky V, Varela E, Dávolos JR: Argon plasma coagulation for prevention of recurrent bleeding from GI angiodysplasias. Gastrointest Endosc 2004, 60:881-886.
• [31]Saperas E, Videla S, Dot J, Bayarri C, Lobo B, Abu-Suboh M, Armengol JR, Malagelada JR: Risk factors for recurrence of acute gastrointestinal bleeding from angiodysplasia. Eur J Gastroenterol Hepatol 2009, 21:1333-1339.
• [32]Zuckerman GR, Cornette GL, Clouse RE, Harter HR: Upper gastrointestinal bleeding in patients with chronic renal failure. Ann Intern Med 1985, 102:588-592.
• [33]Vargo JJ: Clinical applications of the argon plasma coagulator. Gastrointest Endosc 2004, 59:81-88.
• [34]Watson JP, Bennett MK, Griffin SM, Mattewson K: The tissue effect of argon plasma coagulation on esophageal and gastric mucosa. Gastrointest Endosc 2000, 52:342-345.
• [35]Selinger CP, Ang YS: Gastric antral vascular ectasia (GAVE): an update on clinical presentation, pathophysiology, and treatment. Digestion 2008, 77:131-137.
• [36]Chalasani N, Cotsonis G, Wilcox CM: Upper gastrointestinal bleeding in patients with chronic renal failure: role of vascular ectasia. Am J Gastroenterol 1996, 91:2329-2332.
• [37]Manner H, Enderle MD, Pech O, May A, Plum N, Riemann JF, Ell C, Eickhoff A: Second-generation argon plasma coagulation: two-center experience with 600 patients. J Gastroenterol Hepatol 2008, 23:872-878.
• [38]Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, Sinclair P: International Consensus Upper Gastrointestinal Bleeding Conference Group. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010, 152:101-113.
• [39]Sung JJ, Chan FK, Chen M, Ching JY, Ho KY, Kachintorn U, Kim N, Lau JY, Menon J, Rani AA, Reddy N, Sollano J, Sugano K, Tsoi KK, Wu CY, Yeomans N, Vakil N, Goh KL, Asia-Pacific Working Group: Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding. Gut 2011, 60:1170-1177.
• [40]Andriulli A, Loperfido S, Focareta R, Leo P, Fornari F, Garripoli A, Tonti P, Peyre S, Spadaccini A, Marmo R, Merla A, Caroli A, Forte GB, Belmonte A, Aragona G, Imperiali G, Forte F, Monica F, Caruso N, Perri F: High- versus low-dose proton pump inhibitors after endoscopic hemostasis in patients with peptic ulcer bleeding: a multicentre, randomized study. Am J Gastroenterol 2008, 103:3011-3018.
• [41]Cheng HC, Kao AW, Chuang CH, Sheu BS: The efficacy of high- and low-dose intravenous omeprazole in preventing rebleeding for patients with bleeding peptic ulcers and comorbid illnesses. Dig Dis Sci 2005, 50:1194-1201.
• [42]Liang CM, Lee JH, Kuo YH, Wu KL, Chiu YC, Chou YP, Hu ML, Tai WC, Chiu KW, Hu TH, Chuah SK: Intravenous Non-high-dose Pantoprazole is equally effective as High-dose Pantoprazole in Preventing Rebleeding among Low Risk Patients with a Bleeding Peptic Ulcer after Initial Endoscopic Hemostasis. BMC Gastroenterol 2012, 12:28. BioMed Central Full Text
• [43]Chaimoff C, Creter D, Djaldetti M: The effect of pH on platelet and coagulation factor activities. Am J Surg 1978, 136:257-259.
• [44]Netzer P, Gaia C, Sandoz M, Huluk T, Gut A, Halter F, Hüsler J, Inauen W: Effect of repeated injection and continuous infusion of omeprazole and ranitidine on intragastric pH over 72 hours. Am J Gastroenterol 1999, 94:351-357.
• [45]Hung WK, Li VK, Chung CK, Ying MW, Loo CK, Liu CK, Lam BY, Chan MC: Randomized trial comparing pantoprazole infusion, bolus and no treatment on gastric pH and recurrent bleeding in peptic ulcers. ANZ J Surg 2007, 77:677-681.
• [46]Heindorff H, Wojdemann M, Bisgaard T, Svendsen LB: Endoscopic palliation of inoperable cancer of the esophagus or cardia by argon electrocoagulation. Scand J Gastroenterol 1998, 33:21-23.
• [47]Arendt T, Barten M, Lakne V, Arendt R: Diffuse antral vascular ectasia: cause of gastrointestinal blood loss. Endoscopy 1987, 19:218-220.