Polyp as a Complication of Argon Plasma Coagulation in Watermelon Stomach

Gastric antral vascular ectasia (GAVE), or watermelon stomach, is an uncommon cause of gastrointestinal blood loss and iron-deficiency anaemia, that usually requires periodic blood transfusions. Endoscopic treatments, including endoscopic sclerotherapy, coagulation with Nd:YAG and argon lasers, argon plasma coagulation (APC), heater probe therapy, cryotherapy, and monopolar and multipolar electrocoagulation, are now the approaches of choice [1]. They are effective and safe, reducing transfusion requirements in these patients, although some complications have been reported [2] [3] [4].

Figure 1 Endoscopic appearance of the gastric antrum in a patient with watermelon stomach.

Figure 2 A hyperplastic polyp developed after multiple sessions of argon plasma coagulation.

We report an uncommon complication in a patient with GAVE that had been treated by APC.

A 75-year-old woman, with liver cirrhosis and portal hypertension associated with the hepatitis C virus, had experienced several episodes of anemia (hematocrit below 20 %; normal range 36 % - 47 %) in the previous 10 months, without macroscopic signs of bleeding. Despite oral iron supplementation, she required eight blood transfusions in this period. Upper endoscopy revealed a typical image of watermelon stomach, with visible columns of vessels traversing the antrum in longitudinal folds and converging in the pylorus (Figure [1]), and thus APC treatment was given. Four sessions of APC were required to avoid the need for transfusion. During the last upper endoscopy we observed a peduncular polyp in the previously treated area (Figure [2]). This was removed by polypectomy and histopathological examination showed it to be a hyperplastic polyp.

Although endoscopic treatments for GAVE are safe and effective, some complications have been described. Reported complications of Nd:YAG laser treatment include antral strictures, perforations, development of hyperplastic polyps, and a case of gastric multifocal neoplasia [2] [3]. Although such complications are uncommon after APC treatment, antral stricture [4] [5] and a case of hyperplastic polyp (DM Chaves, personal communication cited in [1]) have been reported following APC. Even though the development of a hyperplastic polyp more usually occurs after Nd:YAG laser treatment, we must consider this possibility when we observe a polyp after APC treatment in a patient with GAVE.

Endoscopy_UCTN_Code_CPL_1AH_2AC

References

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• 2 Geller A, Gostout C J, Balm R K. Development of hyperplastic polyps following laser therapy for watermelon stomach.  Gastrointest Endosc. 1996;  43 54-56
• 3 Bernstein C N, Pettigrew N, Wang K K. et al . Multifocal gastric neoplasia after recurrent laser therapy for the watermelon stomach [abstract].  Can J Gastroenterol. 1997;  11 403-406
• 4 Yusoff I, Brennan F, Ormonde D, Laurence B. Argon plasma coagulation for treatment of watermelon stomach.  Endoscopy. 2002;  34 407-410
• 5 Probst A, Scheubel R, Wienbeck M. Treatment of watermelon stomach (GAVE syndrome) by means of endoscopic argon plasma coagulation (APC): long-term outcome [abstract].  Z Gastroenterol. 2001;  39 447-452