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Watermelon Stomach and Radiation Proctopathy

Watermelon stomach is an uncommon condition which manifests with chronic GI bleeding and iron deficiency anemia. The typical patient is an elderly woman who has some kind of a form of connective tissue disorder. Typically the condition was called GAVE, gastric antral vascular ectasia. The associated conditions present in 62% of the patients were Raynaudís phenomenon, most commonly in 31%, scleroderma and CREST syndrome are also common. In our series atrophic arthritis appears in most patients and it is important to realize that about three-quarters of these will also have pernicious anemia and vitamin B-12 deficiency.

The diagnosis is endoscopic. The characteristic linear vascular telangiectases are seen radiating from the pylorus, on the raised stripes in about one half the patients, flat stripes in 20% and mixed flat and raised, or diffusely scattered regions 11% each. Proximal lesions are seen typically within the hiatal hernia and those are important to recognize because they could be a cause for refractory anemia. It is very important to separate this condition from portal hypertensive gastropathy.

This form is the scattered form and this is fairly uncommon, and if you are ever going to confuse portal hypertension this will be the one, with watermelon stomach. However I think that it still can be easily separated, as Iíll show you in a second. This is the retroflex view showing the typical raised fold with teleangiectasis in the cardia, and this should be treated as well. Now this is a picture of portal hypertensive gastropathy with a typical mosaic pattern, cherry red spots.

Now mean sessions are required, three with a wide range but very few patients get to the higher nine sessions. Mean total energy is about 11,000 joules with patients going up to 40,000 with multiple sessions. There is a significant improvement in mean hemoglobin, from 8-9 to 12, and normalized hemoglobin is seen in 73% of these patients. I think one of the most important factors is there is a significant improvement in transfusion dependency, a drop from 62% to 9%.

This picture shows the arc in action and this, if youíve ever seen a postcard with lightning in the desert, this is what exactly this looks in therapy. This is watermelon stomach following therapy and you can see that all of the lesions on top of the folds have disappeared. The argon plasma also enables you treatment with less bleeding and less obscuring of your endoscopic field. Here we see there is some bleeding, but with further application you can easily stop this bleeding.

Now laser therapy, or endoscopic therapy, has some sequelae. One of the common ones with deep injuries is the post coagulation syndrome. The patients present with significant abdominal pain, sometimes with peritoneal signs. It is very important, however, they do not have free air in the abdomen. Therefore conservative therapy should be employed and you should not allow your surgeon to just jump in and open the patient. Cicatricial and antral deformity will be seen in about a third of the patients, however it will not cause clinical symptoms. We have described the development on large antral hyperplastic polyps in 7% of these patients in the laser treated areas. These are the large polyps and these do not usually cause a problem, however in some patients with refractory anemia this is the cause. These polyps can significantly bleed and therefore it needs to be treated. In patients who do not have residual watermelon stomach, simple polypectomy should do the trick. In some patients the polyp is so large that they can be seen prolapsing back into the pylorus.

In summary, watermelon stomach is an easily diagnosed disease. You can make the diagnosis at the bedside. Endoscopic therapy is the treatment of choice. The benefits of endoscopic therapy are long lasting, and one has to remember vitamin B-12 deficiency as a possible cause for refractory anemia. It is imperative to remember that portal hyperplastic gastropathy does not respond to endoscopic therapy.

Now, Iím not going to lose your attention yet. Iím going to show you a brief video of watermelon stomach and then we will go to the next topic. The endoscope down in the antrum and you are very happy that you told Mrs. Smith that you know what she has. Itís interesting that in patients with watermelon stomach, one of the hypotheses is that the condition is associated with trauma from antrum motility and you do see a lot of antrum motility in these patients.

Okay, we will go through the second topic and thatís radiation proctopathy. Again, an uncommon condition. A cause of chronic GI bleeding related to radiation therapy. Radiation colitis however is a misnomer as inflammation is not part of this syndrome. Mucosa and schema of telangiectasis are the suggested pathology. It is important to realize that radiation tolerance is about equal to the therapeutic dose in the colorectum. Radiation therapy can cause chronic radiation injury that will lead to long term complications, one of which is bleeding. The rectum is involved in 90% of these patients and it is thought that proximity to the pelvic organs treated and its relative immobility is the cause. The incidence is only 5-10% of patients receiving radiation proctopathy to the pelvis will develop radiation proctopathy. The median age is about 73. Males in about 72%. Hematochezia is the main presenting symptom, and again most of the patients, 57%, are transfusion dependent.

The typical telangiectasis, thin tortuous vessels that could be in a relatively dense or less dense appearance. This is a fairly involved rectum. Now the involvement can be even higher in the sigmoid and this is a view of the retroflex rectum with significant involvement, however, even with a small involvement around the dentate line you can have hematochezia and patients could be transfusion dependent.

Now pharmacological therapy has not been successful. There are lots of anecdotal cases but I am not going to go into them. Surgical therapy in most cases involves diversion colostomy however it does not result in cessation of bleeding. For that you need rectal sigmoid resection. However in this morbid patient population there is significant morbidity and mortality.

Laser photocoagulation has been proved fairly effective. The goal is to treat circumferentially. To start from the proximal aspect in the dependent portions because bleeding can obscure those lesions. In our series, mean laser sessions up to nine sessions were used. Mean energy was about 8,000 and the contact method around the dentate line was used in 8% of patients. Daily hematochezia has significantly improved from 85-11%, and resolution of hematochezia in 79% of patients. The hemoglobin level improved from almost 10 to almost 12. Transfusion dependency significantly decreased to 9%. And a lasting response was seen in the large majority of these patients.

Again, the argon plasma, Iím not going to repeat the slide. Itís an easy and effective tool for the treatment. This is a slide showing the area after argon plasma coagulation. You will see the probe and you want to perform a white coagulum. Now intraluminal formalin is a relatively new treatment that has been shown to be effective for radiation proctopathy. It initially originated from the field of urology when they had a problem treating hemorrhagic radiation cystitis. However they stopped when the formalin reached the kidneys and patients developed renal failure. In three series of 40 patients, in the literature, 1-3 sessions were required. Bleeding stopped in 75-88% with significant improvement in the rest of the 19% of patients.