Bevacizumab in combination with octreotide rescues a patient with liver cirrhosis, GAVE syndrome and refractory hemorrhage – a case report

Abstract

Gastric antral vascular ectasia (GAVE) syndrome is a rare but often challenging etiology of upper gastrointestinal bleeding (UGIB).

We report on a 60-year-old patient with liver cirrhosis, GAVE syndrome and recurrent and refractory GAVE-related UGIB. During a 5-month hospital stay, the patient required a total of 82 packed red blood cells (pRBCs) and 23 gastroscopies. All endoscopic approaches, including multiple argon plasma coagulation and band ligation sessions, remained unsuccessful. Antrectomy was waived because of the high perioperative mortality risk in Child-Pugh B liver cirrhosis. TIPS insertion also failed to control the bleeding. Only continuous intravenous octreotide infusion slowed the bleeding, but this forced the patient to be hospitalized. After 144 inpatient days, administration of subcutaneous octreotide allowed the patient to be discharged. However, the patient continued to require two pRBCs every 2–3 weeks. Based on recently published data, we treated the patient with bevacizumab (anti-VEGF antibody) off-label at a dose of 7.5 mg/kg body weight every three weeks in nine single doses over six months. Since the first administration, the patient has remained transfusion-free, has not required hospitalization, and leads an active life, working full-time. He remains on octreotide, which has been reduced but not yet discontinued. Additionally, no adverse events were observed.

Thus, in patients with liver cirrhosis and refractory GAVE-related hemorrhage, bevacizumab combined with subcutaneous octreotide should be considered as an effective and durable pharmacological treatment option.

Zusammenfassung

Das „Gastric antral vascular ectasia“ (GAVE-) Syndrom ist eine seltene, aber häufig herausfordernde Ursache der oberen gastrointestinalen Blutung (OGIB).

Wir berichten über einen 60-jährigen Patienten mit Leberzirrhose, GAVE-Syndrom und rezidivierenden, therapierefraktären GAVE-assoziierten OGIBs. Während eines 5-monatigen Krankenhausaufenthalts benötigte der Patient insgesamt 82 Erythrozytenkonzentrate (EKs) und 23 Gastroskopien. Alle endoskopischen Maßnahmen, einschließlich mehrfacher Argonplasmakoagulationen und Bandligaturen, blieben erfolglos. Auf eine Antrektomie wurde aufgrund des hohen perioperativen Mortalitätsrisikos bei Child-Pugh-B-Leberzirrhose verzichtet. Auch eine TIPS-Implantation konnte die Blutung nicht stillen. Eine kontinuierlich-intravenöse Octreotid-Infusion verlangsamte die Blutung, verlangte jedoch eine dauerhafte stationäre Behandlung. Nach 144 Tagen konnte der Patient durch die Umstellung auf eine subkutane Octreotid-Gabe schließlich entlassen werden. Der Patient blieb jedoch weiterhin transfusionsbedürftig. Auf Grundlage kürzlich veröffentlichter Daten behandelten wir den Patienten off-label mit Bevacizumab (Anti-VEGF-Antikörper) mit einer Dosis von 7,5 mg/kg Körpergewicht alle 3 Wochen in 9 Einzeldosen über 6 Monate. Seit der ersten Gabe wurden weder Transfusionen benötigt, noch musste der Patient stationär behandelt werden, sodass wieder eine aktive Teilnahme am Leben möglich ist. Die Octreotid-Dosis konnte zwar reduziert, jedoch noch nicht abgesetzt werden. Unter der Therapie mit Bevacizumab wurden keine unerwünschten Arzneimittelnebenwirkungen beobachtet.

Bei Patienten mit Leberzirrhose und refraktärer GAVE-assoziierter Blutung sollte Bevacizumab in Kombination mit subkutanem Octreotid als wirksame und dauerhafte pharmakologische Behandlungsoption in Betracht gezogen werden.

Schlüsselwörter

GAVE - Leberzirrhose - Octreotid - Bevacizumab - Kasuistik - Wassermelonenmagen

Keywords

GAVE - liver cirrhosis - octreotide - bevacizumab - case report - gastric antral vascular ectasia

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