Endoscopic Diagnosis and Treatment of Watermelon Stomach

Introduction

Watermelon stomach (gastric antral vascular ectasia) is a macroscopic endoscopic diagnosis referring to red, angiomatous (or ectatic) lesions in the antrum of the stomach, associated with gastrointestinal hemorrhage [1] [2] [3]. Two different patterns have been described [4] [5]:

In the first, there are multiple red stripes, often raised, in the antrum that radiate to the pylorus, where they stop (Figure 1). The etiology is idiopathic in most patients, the majority of whom are elderly women. Frequently, watermelon stomach is associated with autoimmune or connective-tissue diseases, such as primary biliary cirrhosis, hypothyroidism, Raynaud’s phenomenon, atrophic gastritis, or pernicious anemia 6. Watermelon stomach lesions may coalesce, resembling a honeycomb. In some patients, antral lesions may be associated with vascular ectasia in the gastric cardia 7 (Figure 2). The second pattern is more diffuse, consisting of numerous antral ectasias arranged not in arrays, but rather in a pattern of small, flat spots, primarily in the antrum, and usually associated with portal hypertension 4. Most patients have advanced cirrhosis, and there is no gender predominance with the diffuse form (Figure 3).

Figure 1 Watermelon stomach: array pattern. a Before treatment. b During heater-probe treatment. c Just after endoscopic treatment.

Figure 2 Watermelon stomach with cardia ectasia, as seen in patients with portal hypertension.

Figure 3 Watermelon stomach: diffuse type. a Before treatment. b During hemostasis with argon plasma coagulation. c Just after treatment.

Biopsies may confirm the presence of mucosal ectasia without inflammation (Figure [4]). The typical histopathological appearance consists of hypertrophy of the antral mucosa, dilation of mucosal capillaries with focal thrombosis, and fibromuscular hyperplasia of the lamina propria. However, ectasias may be missed on biopsy and histopathology using standard techniques in as many as 50 % of cases, either because of shrinkage during fixation, sampling error, or a deeper submucosal location of the ectasia [1].

Figure 4 Histopathological findings in watermelon stomach after biopsy with jumbo forceps. Note the ectatic channels in the mucosa and the lack of inflammatory cells (no ”gastritis”). The biopsy is also relatively superficial, with no muscularis mucosae, and no large vessels are seen.

The most common clinical presentation of watermelon stomach is slow gastrointestinal bleeding and iron-deficiency anemia. However, some patients with coagulopathies or end-stage liver disease present with signs of overt gastrointestinal bleeding such as melena or hematochezia. Watermelon stomach may be overlooked as ”gastritis” (red mucosa), or may not be recognized due to blood in the antrum, or because of hypovolemia, with hypoperfusion of the mucosa [1] [2] [3].

In a large referral population of patients with obscure gastrointestinal hemorrhage, watermelon stomach accounted for 3.9 % of cases (eight of 206) [8]. The referring endoscopists had not recognized the watermelon stomach pattern in these cases, or had depended on biopsies that were interpreted as ”gastritis”.

Medical therapy (such as estrogen-progesterone [9]), surgery with antrectomy, and radiography-guided procedures (such as transjugular intrahepatic portosystemic shunt in the diffuse form with portal hypertension) are the nonendoscopic treatments that have previously been used to treat watermelon stomach. Antrectomy is a very effective treatment for watermelon stomach, but the high surgical risk in most patients has limited its application.

Endoscopic treatments are now the standard of care in most countries, particularly for the classic watermelon stomach pattern. Different endoscopic techniques that have been used for treatment of watermelon stomach are Nd:YAG laser and argon laser [10] [11], monopolar electrocoagulation [12], multipolar electrocoagulation [1] [8], heater probe [1] [13], cryotherapy [14] and argon plasma coagulation [15] [16] [17] [18].

Good results with Nd:YAG or argon laser have been reported, improving both anemia and the endoscopic appearance in most patients. However, the high costs and inconvenience of endoscopic lasers have limited their use to a few centers. In addition, severe complications have been reported, such as secondary bleeding from induced ulcers, gastric perforation, and antral stenosis. Argon plasma coagulation (APC), heater-probe treatment, and multipolar coagulation probe treatment are now more widely available in endoscopy units. These devices are convenient and yield good results, with very low complication rates, in the treatment of watermelon stomach.

This review describes three endoscopic techniques for achieving hemostasis in patients with watermelon stomach: APC, multipolar coagulation (Gold probe), and heater-probe treatment; discusses the advantages and disadvantages of these three techniques; describes outcomes, complications, and results; and contrasts the responses to endoscopic hemostasis of the two types of watermelon stomach - the array and diffuse patterns.

References

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