Endoscopic band ligation: a novel therapy for bleeding gastric antral vascular ectasia

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We report the first case of bleeding gastric antral vascular ectasia (GAVE) treated successfully by endoscopic band ligation after failure of argon plasma coagulation (APC) to achieve hemostasis.

A 55-year-old woman presented with a 1-month history of recurrent melena and severe anemia (hemoglobin 4.5 g/dL) caused by severe bleeding from GAVE of idiopathic origin. She was transfused with 4 units of packed red blood cells. She underwent two sessions of APC in an attempt to achieve hemostasis but responded suboptimally, and the melena recurred within 2 weeks with a drop in the hemoglobin from a post-transfusion level of 11.0 g/dL to 7.9 g/dL (Figure [1]). Endoscopic band ligation was considered as a salvage therapy for the APC-refractory GAVE lesion and two sessions were performed with a 2-week interval between them by applying five and eleven rubber bands respectively in the antrum (Figure [2]). After the endoscopic band ligation, there was clinical and endoscopic improvement and a rise in the hemoglobin to 10.4 g/dL (Figure [3]). The adverse effects after banding were epigastric pain requiring oral analgesia and ulcers at the sites of band application, which healed completely (Figure [4]). In the 15 months of follow-up after the band ligation no gastrointestinal bleeding occurred and her hemoglobin remained stable, with persisting improvement of the endoscopic lesions (Figure [5]).

Figure 1 Heavily bleeding lesions of gastric antral vascular ectasia (GAVE) after two sessions of argon plasma coagulation.

Figure 2 The bands applied at the endoscopic band-ligation procedure, seen here to be occupying the entire antrum (up to the incisura angularis) that was affected by GAVE.

Figure 3 Endoscopic view showing almost complete disappearance of the severe GAVE lesions after the second session of endoscopic band ligation.

Figure 4 Ulcers (with white bases) in the antrum at the site of previous band applications.

Figure 5 Eradication of the GAVE lesions was confirmed at follow-up 8 months after the endoscopic band ligation.

GAVE is an important cause of overt or occult gastrointestinal bleeding, and mainly affects elderly women [1]. Occult blood loss is the most common feature, and transfusion dependence is seen in a half to two-thirds of cases. Because of a lack of randomized trials, the best treatment modality remains unknown, but APC is currently the most common and popular method of treatment [2] [3].

We used endoscopic band ligation to treat GAVE in this patient because of its proved safety, effectiveness, and simplicity in achieving hemostasis in variceal and various nonvariceal gastrointestinal bleeding conditions [4] [5]. Unlike APC, endoscopic band ligation can be applied all over the antrum in a single session without causing the discomfort associated with excessive gaseous distension, and because it is a very simple and cost-effective method that does not require any costly equipment, accessories, or advanced training. Its simplicity, safety, and cost-effectiveness make it a superior alternative to APC for the treatment of bleeding GAVE, especially in countries with limited resources. In conclusion, endoscopic band ligation is a novel therapy for GAVE and can also be used as a salvage therapy if other treatment modalities fail.

Endoscopy_UCTN_Code_TTT_1AO_2AZ

References

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