“Watermelon” Stomach: a Rare Cause of Chronic Iron Deficiency Anemia

Aim. Demonstration of the rare in general medical practice cause of iron deficiency anemia in a patient with acute and chronic blood loss from vascular ectasias of the gastric mucosa.

Key points. Iron deficiency anemia is one of the most common diseases in the world. The most common cause of anemia in gastroenterological practice is chronic or acute blood loss. Gastric antral vascular ectasia, or GAVE syndrome, is the cause of 4% nonvariceal bleeding from the upper gastrointestinal tract. Diagnosis of the disease requires careful endoscopic and histological examination to differentiate GAVE from similar changes (e.g. portal hypertensive gastropathy) and to choose the correct treatment ways. The presented clinical case demonstrates the difficulties of diagnosing the disease in a polymorbid patient, refractory to endoscopic treatments.

Conclusion. GAVE syndrome is a rare but clinically significant cause of bleeding from the upper gastrointestinal tract. GAVE syndrome may be asymptomatic or accompanied by a clinical picture of anemia or obvious bleeding. Endoscopic treatment using argon plasma coagulation is considered first-line therapy in patients with GAVE syndrome, but most authors confirm the high rate of recurrence of gastrointestinal bleeding after the procedure. The presented clinical case clearly demonstrates a difficult path to the diagnosis of GAVE syndrome, which was finally verified after 7 years of follow-up of a patient with severe, refractory to the therapy iron deficiency anemia, only when a typical endoscopic picture of vascular ectasias in the antrum of the stomach organized in radial bands — the “watermelon” stomach was formed.

At the same time, even the use of modern endoscopic treatment methods was not effective.

1. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1211–59. DOI: 10.1016/S0140-6736(17)32154-2

2. Drapkina O.M., Avalueva E.B., Bakulin I.G., Vinogradova M.A. et al. Management of patients with iron deficiency anemia at the stage of primary health care: a practical guide. M.; 2022. 88 p. (in Russian). DOI: 10.15829/ROPNIZ-zda-2022

3. Trukhan D.I., Degovtsov E.N., Nikonenko V.A., Samoilov D.V. Iron deficiency anemia in the practice of a gastroenterologist and surgeon: current aspects of diagnostics and treatment. Consilium Medicum. 2020;22(8):71–7. (in Russian). DOI: 10.26442/20751753.2020.8.200357

4. Camaschella C. Iron deficiency. Blood. 2019;133(1):30–9. DOI: 10.1182/blood-2018-05-815944

5. Rider J.A., Klotz A.P., Kirsner J.B. Gastritis with veno-capillary ectasia as a source of massive gastric hemorrhage. Gastroenterology. 1953;24(1):118–23. DOI: 10.1016/S0016-5085(53)80070-3

6. Jabbari M., Cherry R., Lough J.O., Daly D.S. et al. Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology. 1984;87(5):1165–70.

7. Alkhormi A.M., Memon M.Y., Alqarawi A. Gastric antral vascular ectasia: a case report and literature review. J. Transl. Int. Med. 2018;6(1):47–51. DOI: 10.2478/jtim-2018-0010

8. Fortuna L., Bottari A., Bisogni D., Coratti F. et al. Gastric antral vascular ectasia (GAVE) a case report, review of the literature and update of techniques. Int. J. Surg. Case Rep. 2022;98:107474. DOI: 10.1016/j.ijscr.2022.107474

9. Hsu W.H., Wang Y.K., Hsieh M.S., Kuo F.C. et al. Insights into the management of gastric antral vascular ectasia (watermelon stomach). Ther. Adv. Gastroenterol. 2018;11. DOI: 10.1177/1756283X17747471

10. Aryan M., Jariwala R., Alkurdi B., Peter S. et al. The misclassification of gastric antral vascular ectasia. J. Clin. Transl. Res. 2022;8(3): 218–23. DOI: 10.18053/jctres.08.202203.008

11. Nguyen H., Le C., Nguyen H. Gastric antral vascular ectasia (watermelon stomach) — an enigmatic and often-overlooked cause of gastrointestinal bleeding in the elderly. Perm. J. 2009;13(4): 46–9. DOI: 10.7812/tpp/09-055

12. Gralnek I.M., Dumonceau J.M., Kuipers E.J., Lanas A. et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2015;47(10):a1–46. DOI: 10.1055/s-0034-1393172

13. Fuccio L., Mussetto A., Laterza L., Eusebi L.H. et al. Diagnosis and management of gastric antral vascular ectasia. World J. Gastrointest. Endosc. 2013;5(1):6–13. DOI: 10.4253/wjge.v5.i1.6

14. Gilliam J.H. 3rd, Geisinger K.R., Wu W.C., Weidner N. et al. Endoscopic biopsy is diagnostic in gastric antral vascular ectasia. The “watermelon stomach”. Dig. Dis. Sci. 1989;34(6):885–8. DOI: 10.1007/BF01540274

15. Olevskaya E.R., Tarasov A.N. Venous ectasia of gastric antrum. Clinical Medicine. 2016;94(9):693–6. (in Russian). DOI: 10.18821/0023-2149-2016-94-9-693-696

16. Peng M., Guo X., Yi F., Romeiro F.G. et al. Pharmacotherapy for the treatment of gastric antral vascular ectasia: a narrative review. Adv. Ther. 2021;38(10):5065–77. DOI: 10.1007/s12325-021-01912-6

17. Aveiro M., Rodrigues T., Rabadão T., Ferreira F. et al. The use of thalidomide in severe refractory anaemia due to gastric antral vascular ectasia (GAVE) in cirrhosis? Eur. J. Case Rep. Intern. Med. 2020;7(12):002099. DOI: 10.12890/2020_002099

18. Kichloo A., Solanki D., Singh J., Dahiya D.S. et al. Gastric antral vascular ectasia: trends of hospitalizations, biodemographic characteristics, and outcomes with watermelon stomach. Gastroenterology Res. 2021;14(2):104–11. DOI: 10.14740/gr1380

19. Olevskaya E.R., Tarasov A.N. Application of various endoscopic techniques in the treatment of GAVEsyndrome. Endoscopic Surgery. 2016;2:42–4. (in Russian). DOI: 10.17116/endoskop201622242-44

20. Zepeda-Gómez S. Endoscopic treatment for gastric antral vascular ectasia: current options. GE Port. J. Gastroenterol. 2017;24(4): 176–82. DOI: 10.1159/000453271

21. Tantau M., Crisan D. Is endoscopic band ligation the gold standard for gastric antral vascular ectasia? Endosc. Int. Open. 2019;7(12):E1630–1. DOI: 10.1055/a-1006-2763

22. Senzolo M., Realdon S., Zanetto A., Simoncin B. et al. Endoscopic radiofrequency ablation for the treatment of severe gastric antral vascular ectasia in patients with cirrhosis. Eur. J. Gastroenterol. Hepatol. 2021;33(11):1414–19. DOI: 10.1097/MEG.0000000000001889

23. Kwon H.J., Lee S.H., Cho J.H. Influences of etiology and endoscopic appearance on the long-term outcomes of gastric antral vascular ectasia. World J. Clin. Cases. 2022;10(18):6050–9. DOI: 10.12998/wjcc.v10.i18.6050