**5. Management of GAVE**

#### **5.1. Endoscopic management**

The treatment of choice in managing patients with GAVE is endoscopic ablation of the lesions. Pharmacologic or surgical intervention should be considered when endoscopic therapy has failed. Argon plasma coagulation (APC) has become the method most utilized by endoscopist. APC is a noncontact technique that uses argon gas to equally distribute thermal energy. High-frequency current is applied to the tissue with controllable depth of coagulation (roughly 2–3 mm) [39]. Its efficacy ranges from 90 to 100% [40]. Endoscopic band ligation (EBL) and radiofrequency ablation (RFA) are newer and promising techniques in the treatment of GAVE; however, RFA requires additional training and is not readily available in all endoscopic centers [41].

Compared to older laser therapy methods, APC is more user-friendly, manageable, cheaper, and safer. The risk of perforation is very low and limited to very thin-walled structures [42]. The pooled recurrence rate of bleeding is estimated at 36% [43]. Cryotherapy has also been introduced as another means for managing GAVE. It makes use of nitrous oxide to freeze abnormal mucosa and causes superficial necrosis. A pilot study that assessed 12 patients with GAVE and anemia showed that 50% of patients achieved a complete response after cryotherapy [44]. The remaining patients achieved a partial response with decreased transfusion requirements. However, the optimal delivery mechanism and the number of treatments required remain unclear.

Overall, EBL seems to be the safest and has only been associated with minor complications such as abdominal pain [45]. An observational study of 22 patients (9 patients receiving endoscopic thermal therapy vs. 9 patients receiving EBL) reported fewer bleeding in the EBL cohort (67 vs. 23%), as well as fewer treatment sessions for EBL (4.9 vs. 1.9), and a decrease in EBL-related transfusions (−5.2 vs. −12.7) [46]. A prospective study of 21 patients reported a clinical response that was achieved in 19 patients (91%) after a mean of 2.28 endoscopic sessions and a mean of 16 bands applied [47]. Another study comparing the efficacy of EBL vs. APC reported a lower recurrence rate in the EBL cohort (8.3 vs. 68%) [48].

#### **5.2. Medical treatment**

While a variety of drugs have been used to manage GAVE-related bleeding, none has shown to be clinically effective and efficacious as an alternative to invasive methods. Pilot studies with estrogen-progesterone hormone therapy have been shown to control bleeding due to gastrointestinal vascular malformations, including GAVE, with side effects [49–51]. Despite bleeding cessation, GAVE lesions persisted. Reduction of treatment frequency resulted in bleeding relapse, requiring reinstitution of daily therapy for hemostatic control [49, 52, 53]. However, this form of treatment is not well studied and patients are at risk for developing severe side effects, such as menorrhagia and gynecomastia, and increased risk of endometrial and breast cancer [54].

A long acting somatostatin analog, octreotide, has been reported as an effective drug in controlling chronic bleeding due to vascular abnormalities [55]. This may in part be due to the inhibitory effect on neuroendocrine cells, ectatic vessels, and smooth muscle cells [55, 56]. Octreotide also displays antiangiogenic effects and limits the growth of blood vessels [57]. However, octreotide treatment has been unsuccessfully replicated by other authors and thus necessitates further investigation [58]. Success has been reported from the use of corticosteroids, tranexamic acid, thalidomide, and serotonin antagonist [59–63]. However, these treatments have been reported in some case reports and the results have not been confirmed by controlled clinical trials.

#### **5.3. Surgical intervention**

with superimposed red punctate lesions >2 mm in diameter and a depressed white border [33–35]. Severe PHG is associated with flat or bulging red spots, resembling a scarlatina rash

The treatment of choice in managing patients with GAVE is endoscopic ablation of the lesions. Pharmacologic or surgical intervention should be considered when endoscopic therapy has failed. Argon plasma coagulation (APC) has become the method most utilized by endoscopist. APC is a noncontact technique that uses argon gas to equally distribute thermal energy. High-frequency current is applied to the tissue with controllable depth of coagulation (roughly 2–3 mm) [39]. Its efficacy ranges from 90 to 100% [40]. Endoscopic band ligation (EBL) and radiofrequency ablation (RFA) are newer and promising techniques in the treatment of GAVE; however, RFA requires additional training and is not readily available in all

Compared to older laser therapy methods, APC is more user-friendly, manageable, cheaper, and safer. The risk of perforation is very low and limited to very thin-walled structures [42]. The pooled recurrence rate of bleeding is estimated at 36% [43]. Cryotherapy has also been introduced as another means for managing GAVE. It makes use of nitrous oxide to freeze abnormal mucosa and causes superficial necrosis. A pilot study that assessed 12 patients with GAVE and anemia showed that 50% of patients achieved a complete response after cryotherapy [44]. The remaining patients achieved a partial response with decreased transfusion requirements. However, the optimal delivery mechanism and the number of treatments

Overall, EBL seems to be the safest and has only been associated with minor complications such as abdominal pain [45]. An observational study of 22 patients (9 patients receiving endoscopic thermal therapy vs. 9 patients receiving EBL) reported fewer bleeding in the EBL cohort (67 vs. 23%), as well as fewer treatment sessions for EBL (4.9 vs. 1.9), and a decrease in EBL-related transfusions (−5.2 vs. −12.7) [46]. A prospective study of 21 patients reported a clinical response that was achieved in 19 patients (91%) after a mean of 2.28 endoscopic sessions and a mean of 16 bands applied [47]. Another study comparing the efficacy of EBL vs.

While a variety of drugs have been used to manage GAVE-related bleeding, none has shown to be clinically effective and efficacious as an alternative to invasive methods. Pilot studies with estrogen-progesterone hormone therapy have been shown to control bleeding due to gastrointestinal vascular malformations, including GAVE, with side effects [49–51]. Despite bleeding cessation, GAVE lesions persisted. Reduction of treatment frequency resulted in

APC reported a lower recurrence rate in the EBL cohort (8.3 vs. 68%) [48].

with friability or diffuse hemorrhagic gastropathy [36–38].

**5. Management of GAVE**

46 Stomach Disorders

**5.1. Endoscopic management**

endoscopic centers [41].

required remain unclear.

**5.2. Medical treatment**

Surgical intervention is reserved for patients who do not respond to medical and endoscopic therapies. Surgical approaches include gastrectomy and antrectomy, which may be the only reliable approach to achieving a cure. Antrectomy is more commonly used and has clinical efficacy in eliminating bleeding and transfusion dependency, as patients do not report postoperative recurrence of bleeding was associated with multiorgan failure [64]. Portacaval shunts and TIPS have no role in the management of GAVE [11]. In GAVE patients due to underlying cirrhosis, complete resolution of symptoms has been observed following liver transplant, despite persistent portal hypertension [15].
