Evidence that thalidomide is effective in recurrent bleeding from watermelon stomach associated with liver cirrhosis

Introduction: Thalidomide has been shown to be effective in preventing bleeding from gastrointestinal vascular malformations not responding to endoscopic therapy. However, the efficacy of thalidomide in patients with watermelon stomach associated with liver cirrhosis has not yet been studied adequately.

Case report: An 88-year-old woman was admitted to hospital for evaluation of recurrent gastrointestinal bleeding on August 31^st, 2012. There was a history of hypertension and osteoporosis and some years before a cryptogenic liver cirrhosis had been diagnosed.

Gastroscopy revealed small esophageal varices without signs of recent bleeding. The most impressive finding were longitudinal rows of redish stripes radiating from the pylorus into the antrum. A diagnosis of watermelon stomach was made. After exclusion of other bleeding sources within the gastrointestinal tract by colonoscopy and capsule endoscopy, the ectatic mucosal vessels in the antrum were treated with argon plasma coagulation. This treatment was repeated two times during the following weeks because the ectatic mucosal vessels of the antrum rapidly reappeared after argon plasma coagulation. An average of two blood transfusions every two weeks was necessary to maintain a haemoglobin level of about 9 g/dL. On October 16^th, 2012 the patient was set on thalidomide 50 mg bid. On November 7^th 2012 she received two blood transfusions because her haemoglobin level had dropped to 7.5 g/dL. During further follow-up the patient remained stable and her haemoglobin increased continuously. Treatment with thalidomide was stopped on February 15^th, 2013. The patient was last seen on March 5^th, 2013 when her haemoglobin level was 12.6 g/dL.

Discussion: This case provides evidence that recurrent bleeding from a watermelon stomach associated with liver cirrhosis, which cannot be managed by argon plasma coagulation, can be treated successfully by thalidomide. The efficacy of this treatment approach should be evaluated in randomized trials.