Endoscopic band ligation for gastric antral vascular ectasia: time for a new indication?

We read with great interest the study by Zepeda-Gómez et al. [1] on the treatment of gastric antral vascular ectasia (GAVE) with endoscopic band ligation (EBL). Successful therapy for GAVE is often a challenge and the use of EBL may be a good idea to improve the treatment of this rare but significant cause of acute or chronic gastrointestinal blood loss. We would like to share our experience with a patient who had GAVE and was treated in the same way, in order to strengthen some important key messages emerging from this work.

Our patient was an 84-year-old woman who was admitted to our unit with anemia (hemoglobin 6 g/dL) due to GAVE. She had been treated previously with repeated blood transfusions, hormone therapy (estrogen), and repeated sessions of argon plasma coagulation (APC). As she had required repeated hospitalizations for anemia and there was evidence of failure of traditional endoscopic therapy with APC, we decided to treat her with EBL, as described in previous reports in the literature [2] [3] [4] [5]. The patient underwent two sessions of EBL (14 bands in total), and her last follow-up endoscopy showed fibrosis at the site of the previous EBL, with no more potential bleeding lesions. Since the latest EBL session, the patient has not required any more transfusions or been hospitalized again; her hemoglobin levels have remained stable at 9 – 10 g/dL.

We would like to point out how well our patient responded to a well-known and relatively safe procedure such as EBL. As stated in the work of Zepeda-Gómez, EBL requires only a band ligator kit, which is nearly always available in all endoscopy units, while APC is not so widely available and requires more expertise [1]. Moreover EBL also appears to be more effective in the treatment GAVE, as it creates an ischemic obliteration of the mucosa and submucosa, which is replaced with fibrosis, while conventional therapies, such as APC, tend to act only at the superficial layers of the gastrointestinal wall.

Last but not least, EBL seems to be a promising therapy for GAVE, not only in terms of health-related quality of life for the patients, but also in terms of health-related-costs, as the work of Zepeda-Gómez has shown, with fewer transfusions [1] and, in our opinion, a reduction in cost for the equipment and even in the number of procedures required.

We strongly believe that randomized controlled trials should be carried out in order to confirm the superiority of EBL with respect to APC and to achieve the best treatment strategy for patients affected by GAVE.

• References

• 1 Zepeda-Gómez S, Sultanian R, Teshima C et al. Gastric antral vascular ectasia: a prospective study of treatment with endoscopic band ligation. Endoscopy 2015; 47: 538-540
• 2 Sato T, Yamazaki K, Akaike J. Endoscopic band ligation versus argon plasma coagulation for gastric antral vascular ectasia associated with liver diseases. Dig Endosc 2012; 24: 237-242
• 3 Gill KR, Raimondo M, Wallace MB. Endoscopic band ligation for the treatment of gastric antral vascular ectasia. Gastrointest Endosc 2009; 69: 1194
• 4 Wells CD, Harrison ME, Gurudu SR et al. Treatment of gastric antral vascular ectasia (watermelon stomach) with endoscopic band ligation. Gastrointest Endosc 2008; 68: 231-236
• 5 Kumar R, Mohindra S, Pruthi HS. Endoscopic band ligation: a novel therapy for bleeding gastric antral vascular ectasia. Endoscopy 2007; 39: E56-E57