Watermelon Stomach Causes And Treatment

Introduction

Watermelon stomach, also known as Gastric Antral Vascular Ectasia (GAVE) is an ambiguous and serious cause of severe acute chronic gastrointestinal bleeding associated with dilated small blood vessels in the pyloric antrum, which is a distal part of the stomach. The dilated vessels result in intestinal bleeding. It is usually characterised by longitudinal red columns as a result of engorged blood vessels in the lining of the lower part of the stomach which resembles the stripes that appear in a watermelon through which it earned the name "watermelon stomach".

GAVE is most common among females who are 70 years and above. This disease may be associated with chronic medical conditions such as cirrhosis of the liver, heart, and kidney diseases, and diabetes. The major complication involved in watermelon stomach is the indistinguishable loss of blood leading to chronic Iron deficiency anaemia. The histologic hallmark for GAVE includes fibromuscular hypertrophy of the lamina propria, superficial hyperplastic teal mucosa, and capillary ectasia with thrombosis.

Watermelon stomach is an uncommon disease responsible for about 4% of nonvariceal upper GI haemorrhages. Since the disease in question is associated with acute severe blood loss which could eventually result in iron deficiency anaemia therefore there is a need for early diagnosis to prevent the severe damages which could be caused by the disease through medical support. 

Causes

Chronic medical conditions 

GAVE syndrome is not a congenital alteration rather it is an acquired disease and the exact cause of watermelon stomach is unknown but up to 60% of patients with GAVE have ave an autoimmune associated disease and some other: 

• Chronic Medical Conditions such as liver cirrhosis, chronic kidney disease, autoimmune disease, systemic sclerosis, portal hypertension, and Raynaud's phenomenon. The diversity of the underlying medical conditions associated with watermelon stomach propounds that the cause of GAVE may be variable

Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

• NSAIDs (Nonsteroidal anti-inflammatory drugs) such as aspirin are used in treating millions of people daily and due to their clinical consequences they should be taken seriously
• One of the unwanted effects of this group of drugs is acute gastrointestinal bleeding. Irrespective of the administration of the drug be it oral or parenteral it is still bound to have its effect in the case of excessive or non-prescribed usage 
• According to research, this group of drugs inhibits platelet cyclooxygenase thereby blocking the formation of thromboxane A2 and producing a systemic bleeding tendency by impairing the thromboxane-dependent platelet aggregation, therefore extending the bleeding time 

Gastric antral vascular ectasia (GAVE)

• GAVE (Gastric Antral Vascular Ectasia): This causes the blood vessels in the lining of the stomach to become fragile and prone to rupture and bleeding 

Symptoms

Blood in vomit or stool 

• Blood in stool: This occurs in GAVE as a result of a bleeding disorder in your upper gastrointestinal tract which could be overt (obvious) which is characterised by black or tarry stool and occult (hidden)
• Another symptom exhibited by GAVE is haematemesis which means vomiting blood alone or with the stomach contents. The blood colour could range from fresh to bright red or dark and coagulated colours like coffee grounds 

Haematemesis is due to internal bleeding from the upper gastrointestinal tract like the stomach

Abdominal pain 

• Excessive bleeding causes pain at the injured site, in the case of diseases like watermelon stomach where its bleeding occurs in the upper gastrointestinal tract, the pain is felt in the abdomen

The pain is due to the presence of blood outside the circulating system (heart and blood vessels) which irritates tissues thereby leading to inflammation and pain.

Nausea and vomiting

Diagnosis

Physical exam 

• In this method of diagnosing watermelon stomach inspection, auscultation, palpation, and percussion is carried out with the outlook for any occurrence or reaction to abdominal pain

Endoscopy 

• The endoscopy diagnosis of GAVE involves the use of an endoscope, a long flexible tube with a lens at one end, and a video camera at the outer end. This medical procedure allows a doctor to examine the inside of the stomach without performing major surgery
• The diagnosis of GAVE using endoscopy is characterised by red spots, an organised striped pattern (watermelon stomach), and diffused pattern (honeycomb stomach). The site of appearance is at the antrum and its histological pattern is highly specific. It also exhibits a negative response to Beta-Blockers which the use of B2B lockers drugs ineffective for the treatment of GAVE

Biopsy 

• This involves the collection of tissue from a living body for examination to discover the presence, cause, or extent of a disease. In the usage of biopsy for diagnosing GAVE the biopsies of the antral nodules are collected and examined. This procedure shows if the tissues examined have histologic features that define gastric mantra vascular ectasia (GAVE) such as hyperplastic thrombosis in venules, fibro hyalinosis, and spindle-cell (fibroblast) proliferation

Treatment options

Iron supplements and blood transfusions 

• Iron is an essential mineral of the human body and is needed to produce haemoglobin in your body. The absence of this mineral could lead to anaemia which is the case in the iron deficiency anaemia associated with GAVE patients. The intake of iron supplements helps to make more red blood cells released from the bone marrow into the bloodstream
• Blood transfusion on the other hand is prescribed to relatively increase the levels of haemoglobin for the increase of oxygen transport and to reduce the risk of inadequate supply of oxygen to tissue which can lead to multiple organ failure and increases the mortality rate

Endoscopic treatments 

• This is one of the common means of treating GAVE. It includes the use of Argon plasma coagulation (APC). This is a medical endoscopic procedure with a controllable depth of coagulation of about 0.5-3 mm used to control bleeding from certain lesions in the gastrointestinal tract, endoscopy is applied to the tissue using an ionised and electrically conductive gas called argon plasma. In comparison to other procedures used in endoscopic treatment, APC is more manageable, easier to use, cheaper, and safer. Also, it is associated with rare or mild complications
• The efficiency result recorded about APC ranges from 90% to 100% with no further need for blood transfusion and there is also an increase in the level of haemoglobin in almost all patients. Other endoscope treatments have also been discovered in the last years; they are cryptography, band ligation, and radiofrequency ablation. The above other endoscope treatments efficiencies have not been established therefore there is a need to perform large studies before providing any conclusion

Surgery 

• The surgical approach for the treatment of GAVE consists of a surgical procedure called Antrectomy, the surgical removal of a part of the stomach known as the antrum. No patients who have been surgically treated have had a recurrence of bleeding after the surgery which makes the surgical procedure more efficient in the management of GAVE-related bleeding
• Antrectomy is the most frequently performed surgical approach with 89% of cases. The record has it that the procedure has a mortality rate of 6.6%, still,a minimal rate compared to successesses of the procedure. The principal cause of death was multiorgan failure

Prevention and management

Avoiding triggers such as NSAIDs 

• The use of Nonsteroidal anti-inflammatory drugs increases the risk of bleeding due to the exquisite platelet inhibition posed by aspirin for the longest period (7 days) although other examples of this class of drug have significantly less effect such as ibuprofen and diclofenac (1 day) and celecoxib (0 days). NSAIDs are known to be the most commonly used analgesic. NSAIDs should be avoided in patients with rapid bleeding or those with gastrointestinal disease and risk factors. It should be taken into consideration whether you should or should not use IDs. The physician should consider co-administering a PPI, H2,-blocker, or misoprostol and an alternative selection of COX-2 inhibitors should also be considered
• The self-prescription of NSAIDs should be avoided unless discussed with your doctor before consumption as they will be able to prescribe the safest NSAID, at the lowest dose, for the shortest period

Monitoring for symptoms and seeking medical attention promptly 

• Complications from GAVE - related bleeding could be life-threatening therefore there is a need to watch out for symptoms and seek medical advice as soon as possible. Early detection of an illness reduces the severity or complication that comes with it

Regular follow-up appointments 

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• There may be a recurrence of GAVE in patients who already undergo treatment therefore there should be a follow-up by clinical examination and blood tests, in haemoglobin level for at least 3 and 6 months after therapy initiation
• With this, the rate of deterioration will be discovered. Also, the definite disappearance of patients’ clinical signs and cessation of transfusion of packed red blood cells will be discovered

Summary 

Watermelon stomach, also known as Gastric Antral Vascular Ectasia (GAVE) is a serious cause of chronic gastrointestinal bleeding. The name watermelon emerges from the presence of longitudinal red columns as a result of engorged blood vessels in the lining of the lower part of the stomach which resembles the stripes that appear in a watermelon. It is most common among older females who are above the age of 70 years.

It is caused by underlying chronic medical conditions (such as cirrhosis of the liver, chronic kidney disease, systemic sclerosis, portal hypertension, and Raynaud's phenomenon) and the use of NSAIDs. The symptoms exhibited by this disease are blood in stool and vomiting and abdominal pain.

Physical examination, biopsy, and endoscopy are used to diagnose GAVE and its treatment options include iron supplements and blood transfusion, endoscopic treatment, and surgery.