Esophageal vascular ectasia

A 76-year-old man presented with symptomatic anemia and a hemoglobin of 6.5 g/dL. His medical history included aortic valve replacement requiring chronic anticoagulation, Barrett’s esophagus, and gastric antral vascular ectasia (GAVE) previously treated with argon plasma coagulation (APC). After transfusion and reversal of anticoagulation, an esophagogastroduodenoscopy was performed, confirming the presence of Barrett’s esophagus. There was a broad area of friable vascular ectasia extending up the Barrett’s segment from the gastroesophageal junction, with an additional small ectasia at the squamocolumnar junction ([Fig. 1 a, b]). The broad tongue of ectasia within the Barrett’s segment was lifted with submucosal injection of dilute hydroxypropylmethylcellulose, and the esophageal ectasia were treated with APC ([Fig. 1 c]). The patient returned for follow-up endoscopy 9 months later. There were several remaining esophageal vascular ectasia (EVE) ([Fig. 2]) and these were treated with cryotherapy.

Fig. 1 a – c Esophageal vascular ectasia (EVE) within Barrett's esophagus, treated with argon plasma coagulation (APC).

Fig. 2 Residual vascular ectasia in the esophagus at a follow-up endoscopy at 9 months.

We have described the emergence of EVE in a patient with a history of Barrett’s esophagus, who had previously been treated for GAVE. GAVE is an uncommon cause of upper gastrointestinal bleeding and is associated with cirrhosis, portal hypertension, or chronic renal failure [1] [2]. EVE has been previously described in a patient with Fabry’s disease [3]. While ectasia of the gastric cardia often occur in patients with GAVE, ectasia in Barrett’s esophagus have not been previously described. We chose to treat EVE endoscopically with methods previously used for treatment of GAVE [4] [5], however, caution must be taken to minimize the risk of esophageal perforation.

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AG

References

• 1 Foutch P G. Angiodysplasia of the gastrointestinal tract.  Am J Gastroenterol. 1993;  88 807-818
• 2 Regula J, Wronska E, Pachlewski J. Vascular lesions of the gastrointestinal tract.  Best Pract Res. 2008;  22 313-328
• 3 Okano H, Shiraki K, Tsuneoka K. et al . Esophageal vascular ectasia associated with Fabry's disease.  Gastrointest Endosc. 2001;  53 125-126
• 4 Rosenfeld G, Enns R. Argon photocoagulation in the treatment of gastric antral vascular ectasia and radiation proctitis.  Can J Gastroenterol. 2009;  23 801-804
• 5 Feitoza A B, Gostout C J, Burgart L J. et al . Hydroxypropyl methylcellulose: A better submucosal fluid cushion for endoscopic mucosal resection.  Gastrointest Endosc. 2003;  57 41-47