gastric antral vascular ectasia ( gave ) is a rare disorder associated with chronic upper gastrointestinal bleeding that mainly affects elderly women .
it has a unique endoscopic appearance characterized by multiple longitudinal stripes of red vessels ( watermelon stomach ) or a diffuse spread of red vessels ( diffuse antral vascular ectasia ) , which is largely limited to the gastric antrum .
the typical histological findings are superficial hyperplastic gastric antral mucosa , capillary ectasia with thrombosis and fibromuscular hyperplasia in the lamina propria , and abnormal submucosal vasculature .
gave is sometimes found in patients with chronic kidney disease ( ckd ) , regardless of the maintenance hemodialysis therapy administered .
recently , argon plasma coagulation ( apc ) has been frequently used to treat gave . however
we herein present 3 cases of gave associated with ckd that were not previously treated with dialysis .
a 67-year - old woman with ckd stage v [ serum creatinine ( cr ) = 3.14 mg / dl ; egfr = 12.3 ml / min/1.73 m ] caused by biopsy - proven chronic mesangial proliferative glomerulonephritis suffered from loss of appetite and edema with uremia .
laboratory findings showed severe anemia [ hemoglobin ( hb ) = 5.8 g / dl ] despite treatment with recombinant human erythropoietin ( rhuepo ) and intravenous iron administration .
upper gastrointestinal endoscopy showed watermelon stomach at the antrum without active bleeding . despite repeated blood transfusions ,
six months later , the patient was treated with apc , but the anemia persisted .
one month after the first apc administration , a second round of apc treatment was administered , and hemodialysis therapy was initiated ( fig .
her anemia improved , and no additional transfusions have since been performed . a 61-year - old woman with alcoholic liver cirrhosis ( child - pugh class b ) and ckd stage
v ( cr = 3.14 mg / dl ; egfr = 12.6 ml / min/1.73 m ) caused by hepatorenal syndrome was admitted to the hospital .
she suffered from loss of appetite with uremia and had severe anemia ( hb = 4.8 g / dl ) despite administration of rhuepo and intravenous iron .
she also had severe melena , and upper gastrointestinal endoscopy revealed diffuse antral vascular ectasia without esophageal varices or active bleeding . she was treated with apc twice , but frequent blood transfusions were required .
five months after the second apc treatment , the patient was started on hemodialysis because of volume expansion ( fig .
she no longer requires blood transfusions . a 66-year - old woman with ckd stage v ( cr = 6.4 mg / dl ; egfr = 5.7ml / min/1.73 m ) presented with severe anemia ( hb = 4.8 g / dl ) and suffered from lassitude , loss of appetite , and dyspnea with uremia .
the primary cause of ckd was an autosomal dominant polycystic disease with numerous and massive cysts in both the kidneys and liver .
after 8 months of apc sessions , she was treated with another round of apc and started on hemodialysis ( fig .
1 ) . after the induction of hemodialysis , her loss of appetite and lassitude disappeared .
a 67-year - old woman with ckd stage v [ serum creatinine ( cr ) = 3.14 mg / dl ; egfr = 12.3 ml / min/1.73 m ] caused by biopsy - proven chronic mesangial proliferative glomerulonephritis suffered from loss of appetite and edema with uremia .
laboratory findings showed severe anemia [ hemoglobin ( hb ) = 5.8 g / dl ] despite treatment with recombinant human erythropoietin ( rhuepo ) and intravenous iron administration .
upper gastrointestinal endoscopy showed watermelon stomach at the antrum without active bleeding . despite repeated blood transfusions ,
six months later , the patient was treated with apc , but the anemia persisted .
one month after the first apc administration , a second round of apc treatment was administered , and hemodialysis therapy was initiated ( fig .
a 61-year - old woman with alcoholic liver cirrhosis ( child - pugh class b ) and ckd stage v ( cr = 3.14 mg / dl ; egfr = 12.6 ml / min/1.73 m ) caused by hepatorenal syndrome was admitted to the hospital .
she suffered from loss of appetite with uremia and had severe anemia ( hb = 4.8 g / dl ) despite administration of rhuepo and intravenous iron .
she also had severe melena , and upper gastrointestinal endoscopy revealed diffuse antral vascular ectasia without esophageal varices or active bleeding . she was treated with apc twice , but frequent blood transfusions were required .
five months after the second apc treatment , the patient was started on hemodialysis because of volume expansion ( fig .
a 66-year - old woman with ckd stage v ( cr = 6.4 mg / dl ; egfr = 5.7ml / min/1.73 m ) presented with severe anemia ( hb = 4.8 g / dl ) and suffered from lassitude , loss of appetite , and dyspnea with uremia .
the primary cause of ckd was an autosomal dominant polycystic disease with numerous and massive cysts in both the kidneys and liver .
after 8 months of apc sessions , she was treated with another round of apc and started on hemodialysis ( fig .
1 ) . after the induction of hemodialysis , her loss of appetite and lassitude disappeared . moreover ,
her anemia improved , and gave has not recurred . written informed consent was obtained from all 3 patients .
gave is often associated with systemic illnesses such as cirrhosis of the liver , autoimmune connective tissue disorders , bone marrow transplantation , and ckd .
although the pathogenic link remains unclear , vascular ectasia is a significantly more common cause of upper gastrointestinal bleeding in patients with ckd than in those with normal renal function ( 13 vs. 1.3% , respectively ; p < 0.01 ) .
it has been reported that the antral area half - time in these patients is significantly increased when compared with that of healthy controls .
this finding supports the idea that mechanical stress plays an important role in the pathogenesis of gave . in patients with ckd ,
increased mechanical stress of the antrum in uremia - induced weakening of gastric emptiness is thought to contribute to the development of gave . according to another theory , vasoactive mediators have an important pathogenic role in gave .
enhanced gastrin levels , which are known to increase gastric vasodilation , have been observed in patients with gave . however , the pathogenic role of gastrin is not supported by all studies because hypergastrinemia is not invariably present in patients with gave .
prostaglandin e2 is another hormone with vasoactive functions ; in a single study , it was found to be significantly higher in cirrhosis patients with gave than in those without . in another study ,
histological examination showed that neuroendocrine cells containing 5-hydroxytryptamine and vasoactive intestinal peptide were found close to the ecstatic gastric mucosal vessels [ 6 , 7 , 8 ] .
disturbed renal excretion and/or catabolism of these vasoactive mediators in patients with ckd might also be associated with gave .
uremia - induced platelet dysfunction might also be incriminated as a risk factor for antral bleeding .
volume overload has not been reported to be associated with gave , which is sometimes confused with portal hypertensive gastropathy .
however , gave did not improve with treatment for portal hypertension and congestive heart failure because intra - abdominal venous pressure was not necessarily parallel with circulating volume .
moreover , it was reported that gave in a patient with end - stage renal disease improved following a change to continuous ambulatory peritoneal dialysis from hemodialysis .
therefore , volume overload may not be associated with gave . in the 3 patients with ckd
reported in this study , the development of severe anemia was obviously associated with gave before the initiation of hemodialysis , and the patients required frequent blood transfusions despite apc therapy ( fig .
1 ) . none of the 3 patients experienced a relapse of gave after the initiation of hemodialysis .
interestingly , all of the patients experienced severe loss of appetite , and gastrointestinal symptoms disappeared with the initiation of hemodialysis . it was reported that hemodialysis might improve impaired gastric motility and reduce gastrointestinal symptoms in patients with chronic renal failure .
therefore , the improvement in upper gastrointestinal motility is assumed to have resulted in the improvements in appetite and gave .
in addition , the resolution of gave due to the improvement in gastric motility may have resulted in further appetite increase .
a single endoscopic examination often fails to identify gave , which may be a more common complication among patients with end - stage renal disease than is generally considered .
it is known that a number of patients , even those undergoing dialysis , have severe anemia due to gave . in these patients , gave might be associated with multiple factors . however
, mechanical stress in the antrum due to underdialysis might be one of the causes .
in such cases , improvement in dialysis efficiency might contribute to the remission of gave .
according to our theory , a recurrence of gave after the initiation of hemodialysis should be a rare event .
however , we need longer follow - up periods for these patients , because the follow - up periods for our 3 patients ( 28 months ) would certainly be considered short .
we conclude that initiation of dialysis may induce the remission of intractable gave in patients with ckd .
although the cause is still unknown , improvement in uremia - induced mechanical stress in the antrum might contribute to the remission of gave .
we suggest that in patients with renal insufficiency who suffer from gave relapse , it is important to introduce dialysis treatment .
 gastric antral vascular ectasia ( gave ) is currently recognized as an important cause of gastrointestinal bleeding . chronic kidney disease ( ckd ) is associated with a high incidence of gave . 
 we report 3 patients with ckd who presented with severe anemia and were diagnosed with gave ; they were resistant to endoscopic argon plasma coagulation 
 . however , remission of anemia and improvement in gave lesions were observed after the initiation of hemodialysis . 
 the pathogenesis of gave remains largely unknown , but mechanical stress of the antrum could play an important role . 
 this stress may be reduced by hemodialysis through improvement of uremia - associated gastrointestinal symptoms . 
 therefore , the initiation of hemodialysis might be effective for intractable gave in ckd patients . 
Background
Case Reports
Case 1
Case 2
Case 3
Discussion
Disclosure Statement