Clinical Geriatrics

Gastric antral vascular ectasia (GAVE) syndrome is a rare cause of recurrent gastrointestinal (GI) hemorrhage and anemia, and its etiology is unknown. This syndrome is characterized by red patches or spots in either a diffuse or linear array in the antrum of the stomach and has been commonly referred to as “watermelon stomach” because of its typical endoscopic appearance.1 We describe a case of watermelon stomach as seen by wireless capsule endoscopy, missed by preceding multiple endoscopic examinations.

Case Presentation

Ms. V, a 68-year-old woman, was admitted for recurrent episodes of melena and frequent blood transfusion, which had been preceded by several months of upper abdominal pain and nausea without weight loss. Her medical history was significant for iron-deficiency anemia, hypertension, obesity, diet-treated diabetes mellitus, and cerebrovascular accident. The patient had no history of liver or autoimmune connective tissue disease. She did not drink alcohol and did not take nonsteroidal anti-inflammatory drugs. Ms. V’s medications were an oral iron preparation, omeprazole, and ramipril. Upper and lower GI endoscopies done 2 months before were unremarkable.

Physical examination revealed pallor and morbid obesity. She did not have oral and cutaneous telangiectasias. Her abdomen was remarkable for epigastric tenderness without organomegaly. Ms. V’s investigation showed iron-deficiency anemia due to chronic blood loss and hemoglobin 8.2 g/dL. Her serum urea nitrogen, creatinine, albumin, electrolyte, liver enzyme, and bilirubin levels were within normal limits.

Despite careful examination of the upper and lower GI tract during hospitalization, with barium meal and enema, followed by flexible endoscopy, the reason and location of GI bleeding remained unexplained. Abdominal ultrasonography and computed tomography were normal without signs of portal hypertension. Technetium-labeled red blood cell scintigraphy was performed and showed suspected bleeding point in the upper abdomen.

Treatment was initiated with intravenous ranitidine and transfusion of packed red blood cells. During the subsequent weeks, the patient continued to pass black, tarry stools, and her anemia did not respond to recurrent blood transfusions and oral iron supplementation with persistently low hemoglobin concentration.

Wireless capsule endoscopy was then performed. It showed an array of intensely red stripes radiating to the pylorus, resembling the stripes of a watermelon, with oozing hemorrhages (Figures 1 and 2). Biopsy samples were taken from this region of the distal gastric antrum and showed foveolar hyperplasia and superficial vascular ectasia, consistent with GAVE.

Discussion

Gastric antral vascular ectasia syndrome is a rare cause of recurrent GI hemorrhage and anemia, and its etiology is unknown.1 Typical presentations range from occult bleeding causing transfusion-dependent chronic iron-deficiency anemia to severe acute upper GI bleeding.2 It was first described by Rider et al2,3 in 1953, but was accurately defined by Jabbari and colleagues2,4 in 1984. An upper endoscopy revealed longitudinal erythematous stripes that formed lines within the antrum radiating toward the pylorus resembling the stripes of a watermelon, hence the name GAVE or watermelon stomach.1,2 The etiology of this condition remains unknown. Some authors have suggested that watermelon stomach forms as a result of recurrent episodes of antral mucosal prolapse into the pylorus leading to mucosal trauma and ischemia.4 One theory is that GAVE represents an acquired lesion, possibly related to the result of a degenerative process associated with aging.5