Why GIVE a Liver Transplant to Patients with GAVE Syndrome

Gastric Antral Vascular Ectasia GAVE Gastric Antral Vascular Ectasia

Incidence and Etiology More common in females (ratio reversed in cirrhotic population) Elderly-70’s 30% of patients diagnosed also have cirrhosis Other 70% associated with autoimmune diseases 5.7% of all sclerosis patients Etiology commonly thought to be related to abnormal antral motility and mucosal atrophy Gastric hypoacidity may result from presence of excessive amounts of cirulating acid-inhubity intestinal peptides, which the diseased liver fails to metabolise. Study on hypergastrinaemia in cirrhosis of liver- Gut. 1976 September; 17 (9): 700-708. SK Lam.

GAVE vs PHG Diagnosis and Symptoms Treatment GAVE lesions are restricted to antrum, diffuse or linear chronic significant blood loss often resulting in transfusion dependency Only 4% of acute GI bleeds are attributable to GAVE syndrome Portal Hypertensive Gastropathy (PHG) lesions throughout, lesions are diffuse Treatment PHG- responds to portal pressure reduction efforts Beta-blocker TIPS-Transjugular Intrahepatic Portosystemic Shunt Estrogen-Progesterone Endoscopic Argon Plasma Coagulation (APC) Antrectomy- high mortality in cirrhotic patients Liver Transplant

Liver Transplant for GAVE Study out of Mayo Clinic in Jacksonville FL reviewed 597 patients transplanted from February 1998 to June 2003. 345 had EGD prior to OLT, 8 (2.3%) had GAVE pre OLT 3 of 8 had post OLT EGD, GAVE absent in all 3, other 5 had no post OLT gastrointestinal bleeding J Clin Gatroenterol. 2004. Ward EM et al J Clin Gastroenterol. 2004 Nov-Dec, 38 (10): 898-900 Ward EM et al

Patient Demographics 49 y/o F Cirrhosis secondary to NASH (Non-alcoholic steatohepatitis Portal hypertension Hepatic Encephalopathy GAVE syndrome 30% of GAVE cases are associated with cirrhosis and portal hypertension

Clinical Data Labs Interventions Total Bilirubin 0.9-2.0 INR 1.4-1.8 Creatinine 1.2-2.4 Albumin 2.9 Sodium 130’s Platelets 40’s Hemoglobin 6.0-9.5 Interventions H/H checks 2x/week, scheduled outpatient transfusions PRBCs greater than 60 Units over 8 months APC- 7 treatments 29 Hospitalizations in 1 years time-10 for GIB/anemia

UNOS MELD exception request Higher MELDs driven by AKI/HRS MELD exception request denied for: No increased mortality Try APC Recommend live liver donor Not appropriate diagnosis for MELD exception

Patient Update Patient recently transplanted Post OLT course has been quite complicated but no gastrointestinal bleeding Has not had EGD post OLT to confirm resolution

Nursing Implications Correct diagnosis is key for treatment Educating the patient and other care givers about GAVE syndrome Scheduling of serial H/H checks, transfusions, Endoscopic APC Resolves with Liver Transplantation though exact mechanism is unknown