An Exceptional Presentation of “Watermelon Stomach” in a 30-Year-Old Cirrhotic Male

Radhika Salpekar, Keerthan Upadhya, Shiva Prasad

Department of General Surgery, Kasturba Medical College, MAHE, Manipal – 576104, Karnataka, India

Correspondences to: Radhika Salpekar; email: radhika.marsv@gmail.com.

Received: 16 Nov 2021; Revised: 3 Sep 2022; Accepted: 5 Sep 2022; Available online: 6 Sep 2022

Abstract

Gastric antral vascular ectasia (GAVE) is an unusual cause of chronic upper gastrointestinal bleeding commonly described in elderly females, with associated autoimmune diseases, and in cirrhotic males. The entity is characterized by angioectasia in the pyloric antrum, giving its classic streaky “watermelon stripe” appearance. This report highlights the rare presentation of a young 30-year-old male with liver cirrhosis, who presented with anemia and fatigability. Diagnosis of GAVE was made using endoscopy, and trials of argon plasma coagulation were administered. Following this, an antrectomy was performed since there was a further drop in hemoglobin to pre-transfusion levels. The patient made a full recovery with no subsequent dependence on blood transfusions. GAVE can be mistakenly underdiagnosed as a treatable cause of occult gastrointestinal bleeding. This report mandates caution on endoscopy for younger patients with an upper gastrointestinal bleed while taking other more common causes of gastrointestinal bleeding (peptic ulcers, esophageal varices, and non-steroidal anti-inflammatory drugs [NSAID]-induced gastritis) into account.

Key words: Watermelon stomach, Gastric antral vascular ectasia, Argon plasma coagulation, Endoscopy, Antrectomy

Ann Afr Surg. 2023; 20(2): **-**

DOIhttp://dx.doi.org/10.4314/aas.v20i2.11

Conflicts of Interest: None

Funding: None

© 2022 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Introduction

Gastric antral vascular ectasia (GAVE) is an uncommon cause of upper gastrointestinal bleeding that can manifest as chronic iron deficiency anemia requiring serial transfusions (1). The entity is predominantly found in older females and in older males with cirrhosis (2). As it happens, GAVE is typically uncommon in young patients (3). Patients with cirrhosis, among other conditions such as autoimmune disorders, chronic renal failure, diabetes mellitus, and so on, have the most prominent comorbid connection with GAVE (4, 5). GAVE is traditionally diagnosed and widely managed endoscopically (1). Active bleeding episodes have been observed to be frequent in patients in the absence of cirrhosis, necessitating repeated endoscopic ablations (5, 6). Definitive surgical therapy is generally practiced for cases refractory to endoscopic ablation (1).
In this case report, we discuss the identification, disease course, and endoscopic and subsequent surgical management of this compelling entity in a young cirrhotic male. It prompts the idea of being aware of GAVE as an early differential in young patients with an upper gastrointestinal bleed and a possible aggressive surgical approach for a cure.

Case presentation

A 30-year-old man presented with a 3-month history of fatigability and one episode of melena. He was an alcoholic, although he reported abstinence for 4 years. There was no history of acid reflux, difficulty swallowing, or change in appetite. The patient had an unremarkable past surgical and medical history.
On examination, he was moderately nourished and had pallor and bilateral pedal edema. He was hemodynamically stable. Cardiopulmonary and abdominal examination was unremarkable. Digital rectal examination revealed no melena.
Blood tests showed microcytic, hypochromic anemia, with a hemoglobin of 3.6 g/dL (reference range, 13–17 g/dL) and a hematocrit of 11.7% (reference range, 38.3–44.9%). Iron and folate deficiency was found on anemia workup. Biochemistry panel revealed normal renal and hepatic function. Prothrombin time was normal, and the international normalized ratio (INR) was 1.11. He was Child-Pugh 6A with a model for end-stage liver disease (MELD) score of 8.


Figure 1: Oesophago-gastro-duodenoscopy showing punctate erythematous lesions in antrum with active ooze.

Considering his principally upper gastrointestinal symptoms, an endoscopic evaluation was done. Colonoscopy was unremarkable. Esophagogastroduodenoscopy (EGD) (Figure 1) demonstrated several intense punctate angioectasia, with a diffuse ooze in the antrum indicative of possible GAVE. A duodenal biopsy obtained showed chronic duodenitis with no evidence of H. pylori or dysplasia. Contrast-enhanced computed tomography (CECT) of the abdomen was suggestive of a shrunken liver with splenomegaly, and an unremarkable abdominal angiographic study.
As the presentation was not of the classic “Watermelon stripes”, we considered antral gastritis. However, with a lack of erosive lesions and a predominant picture of diffuse angioectasia, we were able to rule out antral gastritis.