Letters to the Editor - Gastric antral vascular ectasia (watermelon stomach)

Dear Editors,

This letter is in regard to the article, "Gastric antral vascular ectasia (watermelon stomach)—an enigmatic and often-overlooked cause of gastrointestinal bleeding in the elderly" published in The Permanente Journal by Nguyen et al.¹ We share our experience managing a patient who mimicked as gastric antral vascular ectasia (GAVE).

A Caucasian male, age 83 years, was referred to our gastrointestinal clinic for iron deficiency anemia. On his six-month routine follow-up, his primary care physician incidentally noticed that his hemoglobin dropped from 14.1g/dL to 12.4g/dL. He denied any complaints of epigastric or abdominal pain, hematemesis, rectal bleeding, melena, or weight loss. He had no history of nonsteroidal anti-inflammatory drug use. His iron studies showed iron level of 43µ/dL, total iron binding capacity 462µ/dL; iron saturation 9% and serum ferritin 13.2ng/mL. His mean corpuscular volume (MCV), vitamin B-12, renal functions, and liver functions were within the normal range. His colonoscopy, performed in June of 2003, was negative. His past medical history was positive for hypertension and hyperlipidemia. There was no liver or spleen enlargement on his physical examination.

Because of his anemia, esophagogastroduodenoscopy was done. This revealed mucosal inflammation with erosion in the gastric antrum, suggesting GAVE (Figure 1). However, the biopsy indicated, Helicobacter pylori gastritis with Warthin-Starry stain showing Helicobacter pylori. He was treated with antibiotics for Helicobacter pylori and given iron supplements. On six-month follow-up, the patient was doing fine with hemoglobin level of 13.8g/dL.

The majority of GAVE patients present with iron-deficiency anemia secondary to occult blood loss. GAVE has an appearance similar to the dark stripes on the surface of a watermelon, thus the name "watermelon stomach" is commonly used.² GAVE is diagnosed by the classic endoscopic appearance and may also be confirmed with endoscopic biopsy, endoscopic ultrasound, tagged red blood cell scan, or computed tomography scan.^2-3

We agree with Nguyen et al that GAVE is an often-overlooked cause of gastrointestinal bleeding in the elderly.¹ Our case is unique in the sense that apparently it looked like GAVE on esophagogastroduodenoscopy, but pathology was different. It is interesting to note that our patient had no history of cirrhosis of liver, autoimmune diseases, atrophic gastritis, CREST syndrome and/or bone marrow transplant. As we do not know the exact pathogenesis of GAVE,¹ if more cases like this are reported, one ponders if Helicobacter pylori also has some role in GAVE syndrome.

Khurram Abbass, MD
Dayton Veterans Affairs Medical Center, Dayton, OH; Wright State University, Boonshoft School of Medicine, Dayton, OH. Email: drkhuramabbass@gmail.com

Waheed Gul, MD
Wright State University, Boonshoft School
of Medicine, Dayton, OH

Salma Akram, MD
Dayton Veterans Affairs Medical Center, Dayton, OH; Wright State University, Boonshoft School of Medicine, Dayton, OH

References

1.    Nguyen H, Le C, Nguyen H. Gastric antral vascular ectasia (watermelon stomach)—an enigmatic and often-overlooked cause of gastrointestinal bleeding in the elderly. Perm J 2009 Fall;13(4):46-9.
2    Abbass K, Akram S, Gul W. An unusual cause of upper GI bleeding: gastric antral vascular ectasia. J Ark Med Soc 2010 Nov;107(6):108, 110.
3.    Herman BE, Vargo JJ, Baum S, Silverman ED, Eisold J. Gastric antral vascular ectasia: a case report and review of the literature. J Nucl Med 1996 May;37(5):854–6.