PICTURES IN DIGESTIVE PATHOLOGY

 

Endoscopic radiofrequency ablation for APC refractory gastric antral vascular ectasia using the HALO90 system in a kidney transplant candidate

 

 

Gemma Ibáñez-Sanz¹, Laura Rivas¹, Eduardo Melilli², Jordi Guardiola³, Carme Baliellas⁴ and Joan B. Gornals¹

¹Endoscopy Unit, Department of Digestive Diseases.
²Department of Nephrology.
³Gastroenterology Unit, Department of Digestive Diseases.
⁴Hepatology Unit, Department of Digestive Diseases. Hospital Universitari de Bellvitge-IDIBELL. Barcelona, Spain

 

 

Introduction

Gastric antral vascular ectasia (GAVE) is a rare but important cause of gastrointestinal bleeding and anemia. Endoscopic ablation, such as argon plasma coagulation (APC), is usually successful, but treatment-refractory cases do occur (1). Recently, radiofrequency ablation (RFA) has been described as an alternative therapeutic option for GAVE, or actinic proctitis, with positive results and minor complications (2-5).

 

Case report

A 60-year-old man with chronic renal failure in hemodialysis, liver cirrhosis, and chronic iron-deficiency anemia (hemoglobin 7.5 g/dL) with transfusion requirements. GAVE was diagnosed after upper endoscopy, without evidence of portal hypertensive gastropathy (Fig. 1A). In the preceding four years his transfusion requirements had increased (2 packed-red-cells monthly) although he underwent 17 APC sessions. An endoscopic ablation of antral lesions with RFA was considered.

 

 

The radiofrequency device was inserted at the gastroscope end. The vascular antral anomalies were treated using the HALO90 system (BARRX Medical, Sunnyvale, CA). In the first session, GAVE lesions received 31 ablations (at 12 Joules/cm²/40 watts), twice per area, with direct and retroverted view (Fig. 2 A-C) for 29 minutes with good patient tolerance. A second session was scheduled at 4 weeks, and 68 ablations were applied for 36 minutes (Fig. 3 A and B). No complications were reported in either session.

 

 

Three months later, the majority of antral lesions had disappeared (Fig. 1B). Hemoglobin increased to 12 g/dL without any further transfusion requirement, and the patient could be included in a kidney transplant waiting list.

 

Discussion

RFA is popular in the context of Barrett's esophagus dysplasia treatment. Only four published case series have reported the utility of RFA in GAVE lesions (2,3).

This clinical case suggests that RFA using the HALO90 system is a real and safe option for chronic bleeding related to refractory GAVE after attempted APC in patients with chronic renal failure and awaiting kidney transplantation.

 

References

1. Patwardhan VR, Cardenas A. Review article: The management of portal hypertensive gastropathy and gastric antral vascular ectasia in cirrhosis. Aliment Pharmacol Ther 2014 Jun 2. doi: 10.1111/apt.12824.         [ Links ]

2. Gross SA, Al-Haddad M, Gill KR, et al. Endoscopic mucosal ablation for the treatment of gastric antral vascular ectasia with the HALO90 system: A pilot study. Gastrointest Endosc 2008;67:324-7.         [ Links ]

3. McGorisk T, Krishnan K, Keefer L, et al. Radiofrequency ablation for refractory gastric antral vascular ectasia (with video). Gastrointest Endosc 2013;78:584-8.         [ Links ]

4. Díez-Redondo P, de-la-Serna C, Vallecillo MA, Núñez H, Gil-Simón P, Pérez-Miranda M. Radiofrequency ablation: A novel and effective treatment of severe bleeding secondary to actinic proctitis. Rev Esp Enferm Dig 2013;9:555-6.         [ Links ]

5. Gutkin E, Schnall A. Gastroesophageal junction tear from HALO 90 System: A case report. World J Gastrointest Endosc 2011;3:105-6.         [ Links ]