Gastric Antral Vascular Ectasia

Definition

• Distinctive pattern of gastric antral vascular changes with an associate distinctive endoscopic appearance

Alternate/Historical Name

• Watermelon stomach (from the endoscopic appearance)

Diagnostic Criteria

• Mucosal vascular capillary ectasia
  • No vascular malformations
  • Submucosa may have tortuous vessels
• Fibrin thrombi in capillaries
  • CD61 may be useful to highlight thrombi
• Edema and hemorrhage
• Fibromuscular hyperplasia of lamina propria
  • May hyalinize
• Mild chronic inflammation in lamina propria
  • Atrophic gastritis with intestinal metaplasia frequently present
    • Endocrine cell hyperplasia may be present
• Microscopic changes may be less spectacular than the endoscopic findings
• Does not respond to lowering of portal pressure, even if associated with cirrhosis
  • Ablation of vessels may help

Clinical

• Predominantly affects adult women
  • Age 40 and older
  • Mean age about 79
• Presents with iron deficiency anemia
• Frequently associated with autoimmune disorders and connective tissue diseases
  • Autoimmune atrophic gastritis
  • Hypothyroidism
  • Primary biliary cirrhosis
  • Reynaud phenomenon, sclerodactyly and CREST syndrome
• Frequently associated with cirrhosis
• Endoscopic appearance
  • Parallel longitudinal red stripes in antrum converging on pylorus
    • “Watermelon stomach”

Robert V Rouse MD
Department of Pathology
Stanford University School of Medicine
Stanford CA 94305-5342

Original posting/updates : 9/9/09, 4/16/10

Differential Diagnosis

Portal Hypertensive Gastropathy	Gastric Antral Vascular Ectasia
Involves fundus and corpus	Involves antrum
Endoscopic diffuse changes	Endoscopic longitudinal stripes
Secondary to cirrhosis	May be associated with cirrhosis
No microthrombi	Microthrombi characteristic
No fibromuscular change or hyalinization in lamina propria	Fibromuscular hyperplasia with hyalinization of lamina propria

Atrophic Autoimmune Gastritis	Gastric Antral Vascular Ectasia
Lacks endoscopic stripes	Endoscopic watermelon stripes
Unremarkable capillaries	Prominent capillary ectasia
No microthrombi	Microthrombi characteristic
No fibromuscular change or hyalinization in lamina propria	Fibromuscular hyperplasia with hyalinization of lamina propria

Atrophic autoimmune gastritis may be associated with GAVE, so no features of AAG exclude the diagnosis of GAVE.

Dieulafoy Lesion / Caliber Persistent Artery	Gastric Antral Vascular Ectasia
Abnormaly large vessel in lamina propria	Capillary ectasia and thrombosis in lamina propria
No specific submucosal lesion	Submucosal vessels may be tortuous
No microthrombi	Microthrombi characteristic
Lamina propria normal except for large vessels	Fibromuscular hyperplasia with hyalinization of lamina propria

Classification / Lists

Gastritis / Gastropathy

• Reactive gastropathy / chemical gastritis
  • Includes most acute gastritis
  • Various causes including:
    • Alcohol
    • NSAIDS and other drugs
    • Bile and/or duodenal contents (alkaline) reflux
      • Frequently post-surgical
• Chronic gastritis and chronic active gastritis
  • Non-atrophic, predominantly antral
    • Includes Helicobacter-associated chronic active gastritis
    • Late stages may have multi-focal atrophy
  • Atrophic, fundic
    • Autoimmune
• Other drug related gastritis
  • Iron
    • Stainable iron crystalline material present
  • Aluminum based antacids (gastric mucosal calcinosis)
    • Small, pink, partially calcified. refractile crystals
  • Kayexalate
    • Rhomboid or triangular, non-polarizable basophilic crystals
  • Chemotherapy
  • See excellent reviews
    • Parfitt and Driman, Hum Pathol 2007, 38:927
    • Srivastava and Lauwers, Histopathol 2007, 50:15
• Hypertrophic/hyperplastic gastritis
  • Menetrier disease
  • Zollinger Ellison syndrome
• Special types
  • Collagenous
  • Lymphocytic
  • Eosinophilic gastroenteritis
  • Granulomatous
• Vascular
  • Gastric vascular antral ectasia (GAVE)
  • Portal hypertensive gastropathy
  • Ischemic
• Infectious
  • Helicobacter
  • Viral
  • Fungal
  • Parasitic

Bibliography

• Noffsinger A, Fenoglio-Preiser CM, Maru D, Gilinisky N.  Gastrointestinal Diseases, AFIP Atlas of Nontumor Pathology, First Series, Fascicle 5, 2007.
• Suit PF, Petras RE, Bauer TW, Petrini JL Jr. Gastric antral vascular ectasia. A histologic and morphometric study of "the watermelon stomach". Am J Surg Pathol. 1987 Oct;11(10):750-7.
• Jabbari M, Cherry R, Lough JO, Daly DS, Kinnear DG, Goresky CA. Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology. 1984 Nov;87(5):1165-70.
• Vesoulis Z, Naik N, Maseelall P. Histopathologic changes are not specific for diagnosis of gastric antral vascular ectasia (GAVE) syndrome: a review of the pathogenesis and a comparative image analysis morphometric study of GAVE syndrome and gastric hyperplastic polyps. Am J Clin Pathol. 1998 May;109(5):558-64.
• Gretz JE, Achem SR. The watermelon stomach: clinical presentation, diagnosis, and treatment. Am J Gastroenterol. 1998 Jun;93(6):890-5.
• Srivastava A, Lauwers GY. Pathology of non-infective gastritis.Histopathology. 2007 Jan;50(1):15-29.
• Westerhoff M, Tretiakova M, Hovan L, Miller J, Noffsinger A, Hart J. CD61, CD31, and CD34 improve diagnostic accuracy in gastric antral vascular ectasia and portal hypertensive gastropathy: An immunohistochemical and digital morphometric study. Am J Surg Pathol. 2010 Apr;34(4):494-501.