This ASG video tip is sponsored by Braintree, maker of the newly approved Suflav and SuTab. Hello, I'm Samit Tiwani with Rockford Gastroenterology Associates in Rockford, Illinois, and this is the ASG video tip on radiofrequency ablation for gastric antral vascular ectasia. I have no relevant disclosures. Gastric antral vascular ectasia, or GAVE, is an uncommon cause of non-variceal upper GI bleeding that most commonly manifests as iron deficiency anemia or occult GI bleeding. Endoscopically, GAVE most commonly appears as longitudinal stripes of dilated mucosal blood vessels emanating from the pylorus, described as watermelon stomach, or it may take a more diffuse form throughout the antrum. Management of GAVE most commonly involves endoscopic treatment using thermoablative techniques, the most widely used being argon plasma coagulation, or APC. Mechanical techniques such as endoscopic band ligation have also been described. Despite these treatments, many patients remain dependent on iron replacement therapy and intermittent transfusions with poor quality of life. Radiofrequency ablation has emerged as an alternative technique for the management of GAVE. Initially used for the management of dysplastic Barrett's esophagus, the indications for RFA continue to evolve. In another video tip, we describe the use of radiofrequency ablation for the management of radiation proctopathy. In this video, we describe the use of radiofrequency ablation for GAVE. Here are some examples of the endoscopic appearance of GAVE, with the classic watermelon stomach appearance on the left and the more diffuse pattern on the right. Here are some additional examples that you can see throughout. Radiofrequency ablation uses an electrosurgical generator to deliver thermal therapy to soft tissue in direct contact with the bipolar RFA electrode to achieve targeted tissue destruction by causing localized coagulation necrosis. Preset parameters of energy and power allow a consistent depth of ablation to be achieved. Several devices are available, including a self-adjusting balloon catheter to provide circumferential ablation within the esophagus and various focal catheters that can be attached to the tip of the endoscope for treatment of areas of non-circumferential disease. There is even an endoscopic catheter that can be inserted through the working channel of the scope. Before starting the procedure, ensure that the procedure is being performed for an appropriate indication. It is also important to consider contraindications, including the ongoing use of anticoagulation in antiplatelet therapy. In the case of gastroenterovascular actasia, radiofrequency ablation can be applied to the area of involvement using any of the focal catheters. These mount over the tip of the endoscope such that the electrode can be oriented in the 6 o'clock or 12 o'clock position. Once the focal RFA catheter is attached to the tip of the endoscope, the scope is advanced into the antrum and the target area for treatment is identified. The catheter is placed in direct contact against the target area. Two to four consecutive pulses of energy can be delivered to the same area before repositioning the electrode to a new area for treatment, as seen in these pictures. Unlike the protocol for Barrett's esophagus, which includes scraping of the coagulum off of the mucosa between RFA applications, in the case of GAVE, the gastric mucosal coagulum is not scraped between applications to reduce the risk of mucosal bleeding. The through-the-scope endoscopic catheter can also be chosen, which can be rotated for direct application. I select the catheter for use depending on the appearance and distribution of GAVE on endoscopic evaluation. For larger areas of involvement, I would choose a focal RFA catheter such as the Barrett's extra-long RFA catheter, and for focal treatment of small areas such as residual disease after prior treatment, I might select the endoscopic catheter. Multiple studies have described the safety and efficacy of RFA for GAVE. A significant benefit to the use of RFA is its ease of use, given its similar technical complexity to APC. It provides a controlled depth and area of treatment due to the nature of application for direct contact. RFA can itself also be used for management of breakthrough bleeding that occurs during treatment. It is also important to consider the potential risks and complications of the procedure, including but not limited to pain, bleeding, perforation, ulceration, and stricter formation. In summary, GAVE is an important cause of iron deficiency anemia and occult GI bleeding. Despite APC, many patients remain dependent upon iron replacement therapy and intermittent transfusions with poor quality of life. RFA offers an alternative, safe, and effective option. Thank you.

radiofrequency ablation

gastric antral vascular ectasia

GAVE

watermelon stomach

thermal therapy