Case study: gastric antral vascular ectasia

In this case, we report an elderly woman who presented with a 5-month history of intermittent melaena, fatigue, and dyspnoea. Oesophago-gastro-duodenoscopy (OGD) revealed multiple angioectatic lesions in the gastric antrum, consistent with gastric antral vascular ectasia (GAVE), without evidence of active bleeding.

This case underscores the diagnostic challenge of GAVE, which often presents with intermittent, non-specific symptoms. Early recognition is essential in older patients with unexplained anaemia, and management should be individualised, balancing bleeding risk against thromboembolic protection, particularly given the high prevalence of vascular, hepatic, and renal comorbidities in this cohort.

Introduction

Gastric antral vascular ectasia (GAVE) is a rare cause of upper gastrointestinal (UGI) bleeding, characterised by ectatic mucosal vessels in the gastric antrum leading to chronic or recurrent blood loss. It accounts for up to 4% of non-variceal UGI haemorrhages,¹ with prevalence increasing in older adults.

Clinical presentation may be acute, with classical signs such as coffee-ground vomiting or melaena, or more insidious, presenting with symptoms of chronic anaemia, including lethargy, exertional dyspnoea, and palpitations.

GAVE is frequently associated with hepatic, vascular, and renal disease. Endoscopic recognition is key, as characteristic antral vascular changes can be identified even in the absence of active bleeding.

Management options include endoscopic therapy (such as argon plasma coagulation or radiofrequency ablation), pharmacological treatment, and supportive care aimed at symptomatic relief and correction of anaemia.^2,3

Case presentation

An 86-year-old woman presented with a 5-month history of intermittent melaena, fatigue, and dyspnoea. Her only notable medication was apixaban for atrial fibrillation. Laboratory investigations revealed a haemoglobin of 74 g/L, with normal liver function tests. Oesophago-gastro-duodenoscopy (OGD) demonstrated multiple angioectasias in the gastric antrum, consistent with gastric antral vascular ectasia (GAVE), without evidence of active bleeding (Fig. 1).

Management consisted of intravenous proton pump inhibitor therapy, supportive care, blood transfusion, and withholding of anticoagulation. Her haemoglobin stabilised over 48 hours, with no further incidences of melaena during her admission. She was subsequently discharged to her nursing home with outpatient follow-up.

Discussion

GAVE diagnosis is often delayed due to intermittent bleeding and subtle symptoms. Clinicians should suspect it in elderly patients with chronic upper gastrointestinal bleeding or unexplained iron-deficiency anaemia. Although uncommon, its prevalence rises with age.

Conservative management may suit frail patients, but treatment must be individualised. Clinicians should carefully balance bleeding risk against thromboembolic risk when managing anticoagulation, particularly in those with metabolic syndrome or elevated venous thromboembolic risk.^2,3

Learning points

1. Consider GAVE in elderly patients presenting with chronic or recurrent iron-deficiency anaemia, even in the absence of overt gastrointestinal bleeding.
2. Endoscopic diagnosis is crucial, as the characteristic “watermelon stomach” appearance can confirm GAVE even when bleeding is inactive.
3. Management should be individualised, balancing the risks of bleeding, comorbidity, and anticoagulation in frail or high-risk patients.

References

1. Nguyen H, Le C, Nguyen H (2009) Gastric antral vascular ectasia (watermelon stomach): an enigmatic and often-overlooked cause of gastrointestinal bleeding in the elderly. Perm J 13(4): 46–49. doi:10.7812/TPP/09-055
2. Gangwani MK, Haghbin H, Hasan F et al. (2025) Comparing endoscopic treatment modalities for gastric antral vascular ectasia: efficacy, safety, and outcomes in a network meta-analysis. J Clin Gastroenterol 59(6): 555–561. doi:10.1097/MCG.0000000000002057
3. Liu F, et al. (2013) Case report of gastric antral vascular ectasia. Open J Intern Med 3(2): 85–87. doi:10.4236/ojim.2013.32020

Tahani Shanta, Care of the Elderly, Conquest Hospital, East Sussex Hospital Trust, UK.

Nathan Siddall, Care of the Elderly, Conquest Hospital, East Sussex Hospital Trust, UK.

Muhammad JH Rahmani, Care of the Elderly, Conquest Hospital, East Sussex Hospital Trust, UK.

Dr MJH Rahmani

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