Cryotherapy for management of endoscopically refractory gastric antral vascular ectasia. These are our disclosures. Gastric antral vascular ectasia or GAVE is a disease of unclear etiology characterized by longitudinal stripes of ectatic vessels running from the gastric pylorus to the antrum. Initial treatment is typically multiple argon plasma coagulation or APC sessions. Re-bleeding rates following APC remains high around 60% and more recently balloon-based cryotherapy has been introduced. Early studies have shown cryotherapy ablation to be an efficacious and safe modality for treatment of GAVE. Our case is that of a 61 year old man with a history of mechanical mitral and aortic valves on Coumadin. One month after his aortic valve replacement the patient was admitted for melanin and found on endoscopy to have diffuse GAVE. The patient was treated with argon plasma coagulation and discharged home on PPI therapy. After this index admission for GAVE the patient had five additional readmissions for melanin over the next four month time period and required over 30 transfusions and underwent a total of six endoscopies with APC for GAVE therapy. The patient was referred for alternative therapy for GAVE. Given the refractory bleeding and need to maintain anticoagulation the decision was made to attempt cryotherapy for management of his condition. There was a moderate amount of bleeding seen in the gastric antrum secondary to GAVE. A cryotherapy balloon ablation system was utilized. The balloon catheter was advanced through the pylorus and was subsequently inflated. A total of 10 sites of spray cryotherapy were applied in the antrum in a circumferential pattern. Two months later, the patient's hemoglobin improved from 7.8 to 8.9, and the patient did not require any further transfusions or hospitalizations during this time period. During the second endoscopy, there was persistent gave, but no active bleeding was seen. A total of eight sites were ablated in the antrum in a circumferential pattern. Two months later, the patient's hemoglobin improved from 8.9 to 11.2, again without requiring additional transfusions or hospitalizations. Repeat endoscopy demonstrated significantly improved mucosa with minimal residual hemorrhagic appearance, a mild, non-obstructing stenosis developed in the antrum. The patient's hemoglobin remained between 11.2 and 11.4 for the subsequent five months without any further additional signs of melanoma. APC is common first-line therapy for gave, however, refractory patients may have persistent bleeding despite treatment. In patients with refractory disease, alternative methods can be used for successful management of gave. Previously reported methods include radiofrequency ablation, endoscopic band ligation, and cryotherapy. This case demonstrates successful utilization of balloon catheter spray cryotherapy for ablation of refractory gave in a patient with the need for continuous anticoagulation.

Cryotherapy

Gastric antral vascular ectasia

Argon plasma coagulation

Balloon catheter spray cryotherapy

Refractory GAVE patients