CAVE - Cardia Antral Vascular Ectasias – A New Identity?

Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Professor of Medicine, Virginia Tech Carilion School of Medicine, Virginia, USA

Anand Dwivedi, MD, and Adil Mir, MD

Carilion Memorial Hospital

Virginia Tech Carilion School of Medicine

Roanoke

During upper endoscopic evaluation of patients with classic gastric antral vascular ectasias (GAVE) we have observed a few patients who also had classic GAVE-appearing lesions in the gastric cardia (Figure 1). 

The submucosal erythema, subepithelial hemorrhages and edema are confined to the short segment distal to the squamocolumnar junction (SCJ) and in most cases not wider than 3-5 mm, but in some instances extending up to 10 mm from SCJ into the fundus (Figure 2). When performing retroflexion it is evident that the “GAVE” of the cardia is clearly localized to that area (Figure 2A, yellow arrows, Fig. 2B NBI, Fig. 2C HDWL, Fig. 1D-F retroflexed views) and does not extend to the fundus.

Using narrow band imaging (Fig. 2B, Fig. 2F) clearly improves visualization and demarcation of CAVE, as we believe this entity should be called. We have sent histologic samples for analysis and the report has been of “classic” GAVE. Indeed, antral mucosa is normally found in three places of the stomach: antrum, pylorus, and cardia! These are the border regions of the stomach. And gastric antral vascular ectasias (GAVE) are classically found in the antrum and pylorus. Therefore, the neo-angiogenesis process would follow similar stimuli including angiopoietin (Ang-1 and Ang-2), vascular endothelial growth factor (VEGF) and tissue reaction with formation of deformed vessels.

Our observation has important implications. First, we believe that naming this condition CAVE makes sense, as it is true antral vascular ectasia of the cardia. Having a separate name or entity may also raise awareness of this condition. Second, and more important, we believe that CAVE is an important cause of slow or ongoing blood loss in patients with GAVE and/or portal hypertension. How many times do we see patients who have undergone successful eradication of GAVE, but are still having anemia? Maybe CAVE is the reason for ongoing blood loss. Our approach is to treat CAVE using argon plasma coagulation (APC). We hope that our publication encourages others to also study this entity.

 Dr. Pablo Cortegoso