Case Report III

GASTRITIS ANTRAL VASCULAR ECTASIA ON

CHRONIC KIDNEY DISEASE AND CHRONIS
HEPATITIS B

Dolly Jazmi
NPM. 2107601020009

INTERNAL MEDICINE RECIDENCY PROGRAM

FACULTY OF MEDICINE SYIAH KUALA UNIVERSITY
Dr. ZAINOEL ABIDIN GENERAL PUBLIC HOSPITAL
BANDA ACEH
2023
 INTRODUCTION
Gastrointestinal (GI) bleeding refers to any bleeding in the GI tract.1,2

Upper GI bleeding (UGIB)  hemorrhage from the mouth to the Treitz

ligament of duodenum.3

Gastric antral vascular ectasia (GAVE) is a rare cause of UGIB that accounts for 4%
of nonvariceal UGBI and is related to either acute or chronic occult bleeding that
appears as iron deficiency anemia.10
Chronic diseases such as cirrhosis of the liver, autoimmune disorders, Raynaud's
phenomenon, chronic renal failure, hypertension, valvular heart disease, bone marrow
transplantation, and acute myeloid leukemia are associated with GAVE and are commonly
found as comorbidities.10,12

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 DESCRIPTION CASE
PATIENT’S IDENTITY

Name : JM

Age : 43 years old

Sex : Male

Date of Admission : 24th October 2022

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HISTORY OF DISEASE

Chief Complaint:
• Melena (black stool)

Medical History:
• The patient complained of having black stool since 1 day before admission to the hospital,
stool presents with asphalt-like color, and comes with a foul smell.
• Frequency: 7 times/day.
• Complaints of fresh red defecation were denied.
• Weakness and paleness.
• Other complaints such as nausea, vomiting (black color or blood) were denied.
• No prior history of long-term NSAID treatment.
• One day before complaining of black stool defecation, the patient underwent hemodialysis for 4
hours.
• Urination was within normal limits

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HISTORY OF DISEASE

Medical History:
• Chronic kidney disease (CKD) stage V on HD therapy for 2 years
• Chronic hepatitis B (+) for 1 year
• Laparotomy (+) for umbilical herniation
• Hypertension (+) for 3 years  valsartan 1x160 mg; bisoprolol 1x5
mg; and amlodipine 1x5 mg

Lifestyle:
• Never smoke before
• Alcohol use (-)
• Often consumed packaged beverages

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PHYSICAL EXAMINATION
General Condition:
• Weak, nutritional status adequate, compos mentis
• BP 153/90 mmHg
• HR 110 x/minutes
• RR 24 x/minutes
• Temp 36,3 C
• SpO2 98% with nasal cannule 4 lpm
Head and Neck:
• CA (+/+), SI (+/+)
• No enlarged lymph nodes

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 PHYSICAL EXAMINATION
Thoracal:
• Symmetrical, vesicular breath sounds, crackles (-/-), wheezing (-/-)
• S1-2 reguler, cardiomegaly (-)

Abdominal:
• Distention (-)
• Normal bowel sounds
• Tenderness in the left hypochondrium region
• Hepatomegaly (-)
• Splenomegaly (-)

Extremities
• No edema, warm acral, CRT < 2 seconds

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 SUPPORTING EXAMINATION

• Laboratory (24/10/2022): Hb 3.2; Hct 9; erythrocyte count 1.1 x 106; platelet

count 210,000; leukocyte count 11,030; Neutrophils 76; Lymphocytes 16; PT
19.3/14.1; APTT 29.9/29.7; INR 1.38; HbsAg Reactive; Albumins 2.40; Ureum
113; Creatinine 10.9

• Urinalysis (25/10/2022): light yellow color, cloudy clarity, positive leukocytes,

positive protein (+2), urine leukocytes 5-10, positive hyaline cast, positive yeast
cells, other parameters were within normal limits.

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SUPPORTING
EXAMINATIONS
Esophagogastroduodenography
(03/11/2022):
 Esophagus in the 1/3 upper part was
within normal limits, the 1/3 middle part
was within normal limits, and there was
a mucosal break > 5 mm in the 1/3
lower part.
 The stomach in the cardia, fundus,
corpus, and pylorus region were within
normal limits while in the antrum there
was a hyperemic mucosa, and
watermelon stomach appearance.
 Duodenum was within normal limits.
 Conclusion: grade B esophagitis and
gastritis antral vascular ectasia
(GAVE).

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Diagnosis

• Gastritis antral vascular ectasis (GAVE)

• CKD stage V on HD therapy
• Esophagitis grade B
• Hypoalbuminemia
• Post laparotomy indicated by umbilical herniation
• Hypertension on therapy
• Chronic hepatitis B

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 Treatment

• Bed rest
• O2 via nasal cannule 2-4 lpm
• Diet sonde via oral 6x200 cc
• Drip omeprazole 80 mg in 50 cc of 0,9% NaCl at a rate of 5 cc/hour (8 mg/hour)
• Bolus. Ocreotide 100mcg, maintenance Dose 25 mcg/hour
• Inj. Ceftriaxone (IV) 2 gr/24 hours
• Inj. Tranexamic acid (IV) 500 mg/8 hours
• Syr. Sucralfate (PO) 3xCII
• PRC transfusion  Hb target 9 g/dL
• Hemodialysis if Hb level > 6 g/dL

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 FOLLOW-UP

• Laboratory (28/10/2022): Hb 5.7; Hct 16; erythrocyte count 2.0 x 106; platelet
count 191,000; leukocyte count 8,690; neutrophil 78; lymphocyte 11; albumins
3.4; urea 102; creatinine 10.6.

• Laboratory (30/10/2022): Hb 7.5; Hct 21; erythrocyte count 2.6 x 106; platelet
count 202,000; leukocyte count 6,330; neutrophil 67; lymphocyte 15; albumins
3.4; urea 102; creatinine 10.6; Calcium 8.3

• A total of 10 PRC bags were administered during in-patient treatment (24-31

October 2022.

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 FOLLOW-UP

• On November 1st, the patient no longer complained of having black stool.

• Laboratory (03/11/2022): Hb 10.6; Hct 30; erythrocyte count 3.6 x 106; platelet
count 274,000; leukocyte count 6,560; segmented neutrophil 69; lymphocyte 19;
Calcium 8.5; Ureum 46; and Creatinine 8,10

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 DISCUSSION
LITERATURE PATIENT

• Upper Gastrointestinal Bleeding (UGIB)  emergency, • Main complaint: melena (black stool) 
variceal and non-variceal bleeding.4,5
• Most common cause: gastric and/or duodenal ulcers,
UGIB.
severe or erosive gastritis/duodenitis, severe or erosive • Possible source of bleeding: use of
esophagitis.8 NSAIDs , chronic hepatitis B, after
• Less common cause: Dieulafoy’s lesion, GAVE.8 laparotomy for umbilical herniation,
• Bleeding manifestations: hematemesis, melena, and
hematoschezia.7,13 vascular ectasia due to chronic kidney
• Ninety percents of melena (black, tarry stool) originates disease.
from close to the Treitz ligament, but it can also come
from the oropharynx, nasopharynx, small bowel, or
colon.3,13
• Sources of bleeding: varicose veins in patients with a
history of liver disease, vascular ectasia in patients with
CKD, PUD in patients with a history of Helicobacter
pylori infection or NSAID use.13

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 DISCUSSION
LITERATURE PATIENT

• UPPER GASTROINTESTINAL • The patient’s with history of CKD, Chronic

BLEEDING Kidney Disease stage V, Chronic Hepatitis
B, initial laboratory results showed severe
• Initial evaluation: thorough history, anemia with Hb of 3.2 g/dL,
physical examination, and laboratory hypoalbuminemia, reactive HbsAg,
assessment. 3
prolonged PT, increased blood urea and
• Laboratory tests: complete blood counts, creatinine.
serum chemistries, liver tests, and • A total of 10 PRC bags were transfused to
coagulation studies.2,7,13 the patient during his stay at our Hospital 
• Severe anemia 13
Hb increased to 10.6 g/dL.

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 DISCUSSION
LITERATURE
Esophagogastroduodenoscopy (EGD)
• The preferred diagnostic method for acute
UGIB is upper endoscopy (high sensitivity
and specificity).15
• A diagnostic endoscopic procedure called an
esophagogastroduodenoscopy (EGD)
allows for visualization of the oropharynx,
esophagus, stomach, and proximal
duodenum.16
PATIENT
• EGD is our preferred method for observing
GI tract lesions in order to locate the
bleeding source.
• Indications: GI source suspected, iron
deficiency anemia with presumed chronic
blood loss.
• EGD Result: grade B esophagitis and
Gastric Antral Vascular Ectasia (GAVE)
• Endoscopy results in our patient showed
mucosal hyperemia accompanied by
erythematous radial stripes resembling the
rind of a watermelon, or better known as
watermelon stomach
.
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 DISCUSSION
LITERATURE PATIENT

The term "watermelon stomach" comes from the endoscopic feature of longitudinal rows
of flat, reddish stripes that resemble the stripes on a watermelon and radiate from the
pylorus into the antrum.8
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 DISCUSSION
LITERATURE PATIENT
Gastric Antral Vascular Ectasia
• GAVE is a relatively uncommon cause of • The primary clinical symptom in our patient
UGIB, making up about 4% of non- is melena (black stool), leading to the
variceal UGIB.10,19,20 diagnosis of UGIB, possibly caused by
• Rider et al. reported GAVE for the first time GAVE from the visualization of EGD
in 1953. 19

• However, it wasn't until the development of

modern endoscopy that it was widely
acknowledged.22
• Jabbari et al. provided the first detailed
description of it in 1984.22
• Typical GAVE clinical findings are
transfusion-dependent chronic iron-
deficiency anemia or severe acute UGIB.
Acute GI bleeding often occurs with
hematemesis or melena.10

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Gastric Antral Vascular Ectasia

• Numerous theories, including mechanical stress, hemodynamic changes, hormonal, and

portal hypertension, have been put forth to explain the pathogenesis of GAVE. 19,22
• Failure of liver processing functions and chronic kidney disease  build of
vasodilating hormones  gastrin, NO, 5-HT, PGE-2  GAVE.22

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GASTRIC ANTRAL VASCULAR ECTASIA

GAVE syndrome has been linked to a number of disease states, including renal
failure, heart disease, liver cirrhosis, bone marrow transplantation, and
autoimmune disease (such as systemic sclerosis, systemic lupus erythematosus,
and atrophic gastritis with pernicious anemia).12,19,23

Iguchi et al reported 3 cases of GAVE in an elderly woman with stage V

CKD.25 In this study, GAVE was correlated to severe anemia, necessitating
routine blood transfusions for the patient. In this study, hemodialysis may
reduce gastrointestinal symptoms and disorders of gastric motility in
CKD patients.25

The correlation between GAVE and liver disease is mostly related to hepatic
cirrhosis.26 GAVE is more common in people with more severe liver disease, and 30%
of patients with the condition have cirrhosis.24,27 It has been hypothesized that one
possible mechanism involves the buildup of substances that are not processed by the
liver and may cause angiogenesis or vasodilatation.28

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 DISCUSSION
LITERATURE PATIENT

• GAVE is frequently mistaken for Portal • The EGD findings in our case revealed a
Hypertensive Gastropathy (PHG) because typical GAVE involving only the antrum
both conditions can occur to individual with and leaving the corpus and cardia
chronic liver disease. 8,29
unaffected.
• PHG has a prevalence of between 20-80%
in patients with cirrhosis and/or portal
hypertension of other nature, and its
pathogenesis is not fully understood. PHG
involves the proximal stomach, with a
mosaic-like pattern encircling polygonal
areas of erythema, while GAVE shows
erythema most commonly arranged linearly
along folds in the antrum

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DIFFERENCES BETWEEN GAVE AND PHG

22
 DISCUSSION
LITERATURE
• GAVE management focuses primarily on
symptoms with the goal of reducing blood loss
through fluid resuscitation, blood transfusion, and
iron supplementation.10
• Argon-plasma coagulation (APC), which
produces thermal coagulation by applying high
frequency electric current that is passed through
with argon gas without direct contact with the
mucosa, is the method that has been the subject of
the most studies evaluating the use of
thermoablative methods in the treatment of
GAVE.10,28,30
PATIENT
• Our preferred treatment focus approach
primarily on symptoms with the goal of
reducing blood loss.
• Therapy in our patient given at the start of
treatment includes
• Bed rest;
• O2 via nasal cannule 2-4 lpm;
• Diet sonde via oral 6x200 cc;
• Drip omeprazole 80 mg in 50 cc of 0.9% NaCl at
a rate of 5 cc/hour (8 mg/hour);
• IV. Ceftriaxone (IV) 2 gram/24 hours;
• IV. Transexamic acid (IV) 500 mg/8 hours;
• Syr. Sucralfate (PO) 3xCII;
• PRC transfusion woth Hb target of 9 g/dL;
• Hemodialysis if Hb level > 6 g/dL.
• APC is unavailable in our service facilities, so
it has not been regarded as therapy.
• After giving therapy for 10 days our patient had
no complaint of black stool defecation and
general condition improved.
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 CONCLUSION
 The GAVE condition identified in the patient is the cause of UGIB
which generally manifests as severe anemia
 The relationship between GAVE and chronic hepatitis B is not clearly
understood
 GAVE condition in male patients with CKD and chronic hepatitis B
remains a complex yet rare case and requires comprehensive
management.

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1.
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Thankyou…

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