Gastric Antral Vascular Ectasia (GAVE) syndrome is an uncommon condition recognized as a source of chronic, slow gastrointestinal bleeding, which leads to persistent iron deficiency anemia. The condition earned the nickname “Watermelon Stomach” due to its distinct visual presentation. This appearance is created by stripes of fragile, dilated blood vessels in the stomach lining that resemble the markings on a watermelon rind, primarily affecting the lower portion of the stomach.
The Physical Mechanism of Watermelon Stomach
Gastric Antral Vascular Ectasia refers to a collection of abnormal, dilated blood vessels located in the antrum, the lower chamber of the stomach. These abnormal vessels, known as ectasias, are confined to the mucosal layer, the innermost lining of the stomach. Histological analysis of affected tissue reveals dilated capillaries, fibrin thrombi, and a proliferation of spindle cells.
One theory for GAVE development involves mechanical stress on the antral mucosa. Strong, disordered muscular contractions (peristaltic waves) may cause the stomach lining to repeatedly prolapse toward the pylorus. This repeated trauma obstructs blood flow and causes damage, resulting in fibrohyalinosis and the formation of fragile, dilated blood vessels. These ectatic vessels are susceptible to rupture because they are exposed to the constant movement of the stomach and the corrosive effects of stomach acid.
When examined via endoscope, GAVE lesions present as rows of flat, red streaks that radiate outward from the pylorus. This pattern of longitudinal stripes gives the condition its “watermelon” name. In some cases, the lesions may appear as a more diffuse, mottled pattern, sometimes referred to as a honeycomb stomach, particularly in patients with co-existing liver disease.
Symptoms and Clinical Presentation
Since GAVE bleeding is typically a slow, constant ooze rather than a sudden hemorrhage, it results in chronic blood loss. This persistent loss often causes the gradual onset of iron deficiency anemia. Patients commonly report fatigue, weakness, and pale skin. Shortness of breath during physical activity is also frequent and directly related to the anemia.
Signs of bleeding may also be more direct, though less common than anemic symptoms. Patients may notice melena (dark, tarry stools caused by digested blood). Acute episodes of significant bleeding can manifest as hematemesis (vomiting blood), which may look like fresh red blood or dark coffee grounds. GAVE syndrome typically does not cause significant stomach pain, meaning symptoms relate to blood loss rather than localized discomfort.
Associated Risk Factors and Underlying Conditions
GAVE syndrome is frequently considered a secondary condition because it is strongly associated with various chronic systemic diseases. Approximately 30% of individuals diagnosed with GAVE also have liver cirrhosis. Liver disease and the resulting portal hypertension are major co-morbidities, though GAVE can occur independently of the liver.
A significant proportion of patients with GAVE have underlying autoimmune or connective tissue disorders. Conditions such as systemic sclerosis, including the CREST syndrome variant, are particularly linked to the development of this abnormality. Other associated chronic conditions include chronic kidney failure, various heart diseases, and diabetes mellitus.
Confirming the Diagnosis and Treatment Methods
Diagnosis of Watermelon Stomach relies on a visual examination of the stomach lining via an upper endoscopy. During this procedure, a flexible tube with a camera is passed down the throat to observe the characteristic red, longitudinal stripes in the antrum. Blood tests confirm the presence and severity of chronic anemia, typically showing low hemoglobin and ferritin levels indicative of iron deficiency.
Treatment aims to stop the bleeding and resolve chronic anemia, with endoscopic therapy being the first-line intervention. Argon Plasma Coagulation (APC) is the most common technique. APC delivers high-frequency electrical current through a jet of argon gas to the affected vessels. The heat safely cauterizes the fragile ectasias, sealing them to prevent further blood loss.
This treatment often requires multiple sessions to fully ablate all abnormal vessels. Supportive care is equally important and involves administering iron supplements, either orally or intravenously, to correct the iron deficiency. For patients with severe, ongoing blood loss, periodic blood transfusions may be necessary. In rare instances where APC fails to control bleeding, alternative endoscopic methods like radiofrequency ablation or surgical removal of the antrum may be considered.