Titel

Endoscopic Band Ligation Versus Argon Plasma Coagulation In Treatment Of Gastric Antral Vascular
Ectasia
:Short Title

Gastric antral vascular ectasia treatment

Authors

Tarek El-Mahdy Korah , MD 1

Elsayed Ibrahim Elshayeb , MD 1

Mohamed Hamdy Badr, MD 1

Ezzat Mohamed Abdalla , M.B.B.CH 1

Institutions

1- Internal medicine department , faculty of medicine , Menoufia university , ShebeenElkom,

Menoufia ,Egypt

Funds

No Fund
Conflict of interests

No conflict of interests
Corresponding author

Name: Ezzat Mohamed Abdalla

Address for correspondence :Berkit El sabaa, Menoufia ,Egypt
Telephone number : 01001131318
E-mail address :[email protected]

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Endoscopic Band Ligation Versus Argon Plasma Coagulation In Treatment of Gastric Antral
Vascular Ectasia

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Abstract

Objective :To evaluate the therapeutic effects of endoscopic band ligation(EBL) as a modality for the
treatment of bleeding from gastric antral vascular ectasia(GAVE) in comparison to argon plasma
.coagulation(APC) in Egyptian patients

Background :Argon Plasma Coagulation (APC) is considered the standard commonly used treatment for
Gastric antral vascular ectasia (GAVE). Recently, the use of banding in the gastric antrum has been
evaluated for the treatment of GAVE.

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Methods:The study was conducted on thirty patients presenting with bleeding from GAVE. The patients
were divided into two groups: Group I (EBL) group: 15 patients were subjected to EBL. Group II (APC)
group: 15 patients were subjected to APC. Sessions were done every 3 weeks till satisfactory endoscopic
ablation was achieved. Regular endoscopic assessment at 3 months was done with documentation of the
recurrence of GAVE if found.
Results revealed that thirteen patients were males and seventeen were females with age ranging from 51-
70 years old.
Most of the patients presented with overt bleeding (hematemesis and/or melena)(65% In the APC group
and 65% in the EBL group). In endoscopic band ligation group, all patients(100%) showed complete
improvement with no recurrence. In APC 12 patients(80%) showed complete improvement with no
recurrence , 3 patients(20 %) showed no endoscopic improvement. EBL results showed better
endoscopic results than APC but there was no statistical significance between both.
In conclusion, Both APC and EBL proved to be effective treatment options for GAVE.
Key words :.Argon Plasma Coagulation .Endoscopic Band Ligation. Gastric Antral Vascular Ectasia

Introduction:

Gastric antral vascular ectasia(GAVE) is considered rare cause of upper gastrointestinal

bleeding(1).The etiology of gastric antral vascular ectasia remains unknown but theories include
hypergastrenemia .A connective tissue disease has been suspected in some cases. Autoimmunity may
have something to do with it, as 25% of all sclerosis patients who had a certain anti-RNA marker have
GAVE. RNA autoimmunity has been suspected as a cause or marker since at least 1996(2)

The diagnosis is mainly based on endoscopic pattern and , for uncertain cases, on histology. GAVE
is characterized by a pathognomonic endoscopic pattern, mainly represented by red spots either

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organized in stripes radially departing from pylorus, defined as watermelon stomach, or arranged in a
diffused-way, the so called honeycomb stomach(3)

The endoscopic treatment of GAVE with thermal therapies such as argon plasma coagulation
(APC) has been successful and provided an alternative treatment option to surgical antrectomy, but
significant limitations as multiple treatment sessions and persistent bleeding are found(4,5)Recently, the
use of banding in the gastric antrum has been evaluated for the treatment of GAVE(6)

Our study was done to evaluate the therapeutic effects of endoscopic band ligation(EBL) as a
modality for the treatment of bleeding from GAVE in comparison to argon plasma coagulation(APC) in
Egyptian patients.

Patients and Methods

This study was conducted on thirty patients with overt or occult bleeding that proved
endoscopically to be originating from gastric antral vascular ectasia(GAVE). The recruited patients
attended the internal medicine department , Menoufia university.
The patients were classified into two groups . Group I (Endoscopic band ligation (EBL) group)
included 15 patients and were subjected to EBL sessions. Group II (Argon plasma coagulation (APC)

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 group) included 15 patients and were subjected to APC sessions. An informed consent was obtained from
all patients.
Patient demographics and pretreatment data were obtained from both the EBL and APC groups.
Pre treatment data including age, sex ,bleeding type , and history of liver disease were obtained .Pre
treatment Complete blood count (CBC) ,hepatitis C virus(HCV) antibody ,hepatits B surface Ag( HBsAg)
and fecal occult blood in stool were done.
In our study, EBL boston scientific band ligation sets were used which were applied to abnormal
GAVE mucosa starting in the antrum followed by ligation proximally until as much as possible abnormal
appearing mucosa be treated.
Standard APC equipment was used ( ERBE Germany ) an automatically regulated argon source
( APC 300 ) , the APC probe 2-3 mm Teflon coated catheter passing through the scope work channel with
argon fluid 2 L / min. APC was applied to the lesion beginning at the pylorus and proceeding proximally
Patients in both groups were reevaluated every 3 weeks. All patients underwent follow-up
endoscopy at 3 months to assess the recurrence of GAVE.

Data on control of bleeding, hemoglobin levels before and after treatment, fecal occult blood test
before and after treatment and endoscopic improvement and recurrence of GAVE were obtained and
.compared between both groups

.Clinical, Laboratory data of the cases were tabulated

Statistical analysis:Data entry, coding, and analysis were conducted using SPSS (20), IBM Corp.
Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.USA.
Statistical tests used:
 •Description of quantitative variables in the form of Mean and Stander Deviation (mean±SD).
 •Description of qualitative variables by frequency and percentage.
 Kruskal Wallis, to estimate the difference of 'Means" of more than two groups.
 Fisher exact test: to assess the relationship between two or more qualitative groups
 The level of significance of our data were 95%, so, p value >0.05 was considered a non-statistically
significant difference, while p value < 0.05 was considered a statistically significant difference. On the other
hand, a p value <0.01 was considered a highly statistically significant difference.

Results
The study was done on 30 patients 13 patients(43.35%) were males and 17 patients (56.65%)were
females with age ranging from 51-70 years old.

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 There was no statistical significance between endoscopic band ligation ligation(EBL) group and
argon plasma coagulation(APC) group regarding laboratory investigations of studied groups 3 weeks after
the procedure. Mean hemoglobin(Hb) 3 weeks after endoscopic band ligation was 9.06 while after argon
plasma coagulation was 9.51 with no significant difference between both ( P value 0.711). Mean white
blood cells(WBCs) 3 weeks after endoscopic band ligation was 6.62 while after argon plasma
coagulation was 6.61 with no significant difference between both ( P value 0.328). Mean platelet count 3
weeks after endoscopic band ligation was 90.1 while after argon plasma coagulation was 85.9 with no
significant difference between both ( P value 0.950)( table 1)

Hemoglobin levels were significantly higher after 3 weeks in patients who underwent endoscopic
band ligation and blood transfusion on admission. Mean Hb before endoscopic band ligation was 7.71
while mean Hb 3 weeks after the procedure was 9.06 which showed significant improvement ( P value
0.001). Mean WBCs before endoscopic band ligation was 5.25 while mean WBCs 3 weeks after the
procedure was 6.62 which showed no significant difference ( P value 0.255) . Mean platelet count before
endoscopic band ligation was 92.7 while mean platelets 3 weeks after the procedure was 90.1 which
showed significant improvement ( P value 0.037).( table 2)

Hemoglobin levels were significantly higher after 3 weeks in patients who underwent APC and
blood transfusion on admission. Mean Hb before APC was 7.25 while mean HB 3 weeks after the
procedure was 9.51 which showed significant improvement ( P value 0.001). Mean WBCs before APC
was 6.79 while mean WBCs 3 weeks after the procedure was 6.61 which showed no significant difference
( P value 0.732) . Mean platelet count before APC was 85.7 while mean platelets 3 weeks after the
procedure was 85.9 which showed no significant difference ( P value 0.431).(table 3)

There was no statistical significance regarding fecal occult blood test(FOBT) in stool between
endoscopic band ligation group and argon plasma coagulation group

3 weeks after endoscopic band ligation 15 patients(100 %) showed negative fecal occult blood test
while after argon plasma coagulation 14 patients(93.3%) showed negative FOBT with 1 patient(6.7%)
showing positive FOBT with no significant difference between both EBL and APC regarding FOBT
results 3 weeks after the procedure(P value 0.309)(table 4)

There was no statistical significance between endoscopic band ligation group and argon plasma
coagulation group in endoscopic follow up results for recurrence of gastric antral vascular
ectasia(GAVE).

In endoscopic band ligation group, all patients(100%) showed complete improvement with no recurrence.
In APC 12 patients(80%) showed complete improvement with no recurrence , 3 patients(20 %) showed

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no endoscopic improvement . EBL results showed better improvement than APC but there was no
statistical significance between both ( P value 0.183)( table 5)

:Discussion

In our study the mean age of patients presented with gastric antral vascular ectasia(GAVE) was
61 years and it was more common in females (56.65%) than males(43.35%)

Selinger and Ang showed that the mean age of patients presenting with bleeding GAVE is 65 years
and it was more common in males (75% of the patients were males) which does not consist with our
results (1)

Manifest bleeding (hematemsis and/or melena) was detected in 20 patients(65%) in the argon
plasma coagulation (APC) group and endoscopic band ligation(EBL) group which is consistent with
Lecleire and colleagues who stated that acute hemorrhage appears to be more frequent.(7)
Fecal occult blood test(FOBT) results 3 weeks after both EBL and APC showed significant
improvement (p value 0.001)

Hemoglobin levels were significantly higher in both APC group and EBL group 3 weeks after the
procedure(p value 0.001)

In our study , no statistical significance between endoscopic band ligation group and argon plasma
coagulation group in endoscopic follow up results and recurrence of GAVE(p value 0.183)

The study done by Wells and colleagues found that treatment of GAVE by EBL showed
significantly better endoscopic results and fewer treatment sessions in comparison to APC (6)

The study done by Sato and colleagues found that treatment of GAVE by APC showed
significantly better endoscopic results and fewer treatment sessions compared to EBL (8)

Conclusion
Both endoscopic band ligation and argon plasma coagulation are effective treatment modalities for
gastric antral vascular ectasia

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:References

1- Selinger, C. P and Ang, Y. S, (2008): Gastric antral vascular ectasia (GAVE): an update on
clinical presentation, pathophysiology and treatment. Digestion ; (77) ; 131-137
2- Shirazian, S., and Radhakrishnan, J. (2010). Gastrointestinal disorders and renal failure:
exploring the connection. Nature Reviews Nephrology, 6(8), 480-492.

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 3- Fuccio, L., Mussetto, A., Laterza, L., Eusebi, L. H., and Bazzoli, F, (2013): Diagnosis and
management of gastric antral vascular ectasia. World journal of gastrointestinal endoscopy ; 5(1):
6.
4- Sebastian, S., R. McLoughlin, A. Qasim,C.A. O'Morain and M.J. Buckley( 2004). Endoscopic
argon plasma coagulation for the treatment of gastric antral vascular ectasia (watermelon
stomach):long-term results. Dig. Liver Dis., 36: 212-217
5- Jensen, D.M., D.M. Chaves and K. Grund(2004).Endoscopic diagnosis and treatment of
watermelon stomach. Endoscopy, 36: 640-647.
6- Wells, C. D., Harrison, M. E., Gurudu, S. R., Crowell, M. D., Byrne, T. J., DePetris, G., et al.
(2008). Treatment of gastric antral vascular ectasia (watermelon stomach) with endoscopic band
ligation. Gastrointestinal endoscopy, 68(2): 231-236.
7- Lecleire, S., E. Ben-Soussan, M. Antonietti, O. Goria, G. Riachi,E. Lerebours and P.
Ducrotté, (2008). Bleeding gastric vascular ectasia treated by argon plasma coagulation: a
comparison between patients with and without cirrhosis. Gastrointest Endosc. Feb., 67:219-225
8- Sato, T., K. Yamazaki and J. Akaike, (2012).Endoscopic band ligation versus argon plasma
coagulation for gastric antral vascular ectasia associated with liver diseases. Digestive
Endoscopy,24: 237-242.

Tables

Table (1): Laboratory investigations of studied groups 3 weeks after the procedure and blood transfusion
on admission

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 Endoscopic Argon Plasma
Band Ligation Coagulation
group group (N=15) Mann P value
)N=15( Whitney
Studied variables
SD± X SD± X test
HB( gm %) 9.06±0.87 `9.51±0.41 *0.374 )NS(0.711
WBCs(cell/cmm)×103 6.62±6.61 6.61±2.99 0.977 )NS(0.328
Platelet (cell/cmm)×103 90.1±39.3 85.9±30.6 0.062 )NS(0.950

χ2= Chi square test No=Number SD=Standard deviation %=percentage *t-test P value:
NS= non-significant (P-value > 0.05), S = significant (P-value ≤ 0.5) HS= highly significant (P-value ≤ 0.001)

HB=hemoglobin , WBCs=white blood cells

Table (2): Laboratory investigations before and after 3 weeks among endoscopic band ligation group

Endoscopic Band Ligation

Studied variables group Wilcoxon P value
Before After test
SD± X SD± X

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 HB( gm %) 7.71±1.33 9.06±0.87 *6.35 )HS(0.001
WBCs(cell/cmm)×103 5.25±3.22 6.62±6.61 1.13 )NS(0.255
Platelet (cell/cmm)×103 92.7±38.6 90.1±39.3 2.08 )S(0.037

χ2= Chi square test No=Number SD=Standard deviation %=percentage *t-test

P value: NS= non-significant (P-value > 0.05), S = significant (P-value ≤ 0.05) HS= highly significant
(P-value ≤ 0.001) HB=hemoglobin , WBCs=white blood cells

Table (3): Laboratory investigations before and 3 weeks after argon plasma coagulation and blood
transfusion on admission

Argon Plasma Coagulation

group

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 Studied variables Before After Wilcoxon P value
SD± X SD± X test
HB( gm %) 7.25±1.28 `9.51±0.41 *7.16 )HS(0.001
WBCs(cell/cmm)×103 6.79±3.44 6.61±2.99 0.342 )NS(0.732
Platelet (cell/cmm)×103 85.7±28.7 85.9±30.6 0.787 )NS(0.431

χ2= Chi square test No=Number SD=Standard deviation %=percentage *t-test

P value: NS= non-significant (P-value > 0.05), S = significant (P-value ≤ 0.05)

HS= highly significant (P-value ≤ 0.001)HB=hemoglobin , WBCs=white blood cells

:Table (4): FOBT among studied groups (N=30)

Endoscopic Argon Plasma

Band Ligation Coagulation

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 group group (N=15)
)N=15(
FOBT .No % .No % χ2 P value

Before
Positive 12 80.0 12 80.0 - -
Negative 3 20.0 3 20.0
After
Positive 0 0.00 1 6.7 1.03 )NS(0.309
Negative 15 100 14 93.3

χ2= Chi square test No=Number SD=Standard deviation %=percentage *t-test

P value: NS= non-significant (P-value > 0.05), S = significant (P-value ≤ 0.05)

HS= highly significant (P-value ≤ 0.001) FOBT= fecal occult blood test

:Table (5): Endoscopic Follow up results and GAVE recurrence among studied groups (N=30)

Endoscopic Argon

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 Band Ligation Plasma
group Coagulation
Follow up (N=15) group χ2 P value
(N=15)
No. % No. %
Improvement (no recurrence) 15 100 12 80
3.39 0.183
No improvement( recurrence) 0 0.00 3 20.0

χ2= Chi square test No=Number SD=Standard deviation %=percentage *t-test

P value: NS= non-significant (P-value > 0.05), S = significant (P-value ≤ 0.05)

HS= highly significant (P-value ≤ 0.001)

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