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Nephrol Dial Transplant (1996) 11: 871-874Case ReportNephrologyDialysisTransplantationWatermelon stomach. An unusual cause of recurrent upper GI tractbleeding in the uraemic patient: efficient treatment withoestrogen-progesterone therapyC. Hermans1, E. Goffin1, Y. Horsmans2, E. Laterre3 and C...  
Nephrol Dial Transplant (1996) 11: 871-874Case ReportNephrologyDialysisTransplantationWatermelon stomach. An unusual cause of recurrent upper GI tractbleeding in the uraemic patient: efficient treatment withoestrogen-progesterone therapyC. Hermans1, E. Goffin1, Y. Horsmans2, E. Laterre3 and Ch. Van Ypersele de Strihou1Departments of Nephrology, 2Gastroenterology, 3Pathology, Cliniques Universitaires Saint-Luc, Louvain Medical School,avenue Hippocrate, 1200 Bruxelles, BelgiumKey words: angiodysplasia; antral vascular ectasia;chronic renal failure; oestrogen-progesterone therapy;watermelon stomach; GI bleedingIntroductionThe gastrointestinal tract is frequently the source ofoccult blood loss in patients on long-term haemodia-lysis. Among the many causes of bleeding, angiodyspl-astic lesions are encountered more frequently inuraemic than in non-uraemic patients [1-5].We report a patient on chronic haemodialysis whodeveloped a rare form of angiodysplastic lesions local-ized in the stomach. Its unique appearance on endo-scopy has justified the name of watermelon stomach(WS) [6]. Its recognition is of interest as it respondswell to an oestroprogestative treatment with eventualdisappearance of repeated bleeding episodes.Case reportA 63-year-old man on chronic haemodialysis wasadmitted to our hospital in June 1994 for severepersistent anaemia.Haemodialysis had been initiated in 1988 for end-stage-renal failure due to chronic glomerulonephritis.The patient had a long history of severe hypertensionand suffered from peripheral vascular disease. Soonafter the onset of dialysis, he developed severe anaemiaresistant to the prescription of iron supplements anderythropoietin and requiring repeated blood transfu-sions (Figure 1). Upper GI endoscopy disclosed, onseveral occasions, antritis despite the administration ofranitidine (300 mg o.d.) and subsequently omeprazole(20 mg o.d.). In November 1991, antral vascular ectasiaCorrespondence and offprint requests to: Dr E. Goffin, CliniquesUniversitaires Saint-Luc, Division of Nephrology, AvenueHippocrate 10, B-1200 Bruxelles, Belgium.typical of WS aspect were diagnosed (Figure 2).Repeated courses of omeprazole (40 mg o.d.) andsucralfate (1 g t.d.s.) did not prevent further digestiveblood loss and anaemia (Figure 1). An extensive work-up in April 1994 including gastroscopy, barium enema,rectoscopy, and sigmoidoscopy confirmed WS andfailed to identify another gastrointestinal lesion.On clinical examination, blood pressure was160/90 mmHg. A murmur was present on the rightfemoral artery and peripheral pulses were absent.Clinical examination was otherwise unremarkable.Relevant blood tests disclosed anaemia (Hb: 6.3 g/dl,mean globular volume: 95.4 u3) and iron deficiency(iron, 38 ug/dl; iron binding capacity, 347 ug/dl; ferri-tin, 13 ng/ml, normal, 10-300) despite recent bloodtransfusions. Gastroscopy confirmed the existence ofWS. Gastric mucosal histology disclosed typical dilatedmucosal capillaries, focal thrombosis (Figure 3a) aswell as fibromuscular hyperplasia (Figure 3b).Hormone therapy (norethisterone 1 mg and ethynyloe-stradiol 0.05 mg; Ovismen R, Cilag, daily) was initi-ated. Within 3 months haemoglobin steadily increased,without further evidence of bleeding. Tolerance to thetreatment was excellent. One year later, no complica-tion has been observed except a single episode ofclotting in the dialysis circuit requiring an increasedheparin dosage. The appearance of a slight gynecoma-sty led to an alternate-day prescription of the hormonesin November 1994, without any evidence of recurrentbleeding (Figure 1).DiscussionThe watermelon stomach has rarely been reported asa cause of digestive bleeding in uraemic patients [2—5].It refers to a localized form of angiodysplasia confinedto the gastric antrum. As shown by the present report,its diagnosis is of critical importance as the prescriptionof an oestrogen-progesterone preparation may providea sustained cure.Angiodysplasia is a vascular lesion of the gastrointes-© 1996 European Dialysis and Transplant Association-European Renal Association by guest on June 5, 2013http://ndt.oxfordjournals.org/Downloaded from 872 C. Hermans el al.Haemoglobin concentration before and afterHaemoglobin(mg/dl)11-10-9-8--ja, \-14 -12 -10 -8 -EPO (103 U/month)| 32OMEPRAZOLEhormonal therapy> 2 2 2 2 3 units of blood\ HI U ^s—a1 III II II III II6-4-2 0 2 4 (40D DDD DOMEPRA-ZOLESUCRAL-FATEHormonal trek. „> 8 1030time(month)1240= IRON 500 mgatmentFig. 1. Blood transfusion requirements and serial haemoglobin concentrations before and after hormone treatment.Fig. 2. Endoscopic photograph of the gastric antrum showing longit- |udinal folds of dilated vessels radiating from the pylorus and "-resembling the skin of a watermelon.tinal tract affecting mucosal and submucosal vessels[7]. The diagnosis rests on an endoscopic image com-prising red lesions, flat or slightly raised above themucosal surface and usually 2-10 mm in size corres-ponding on microscopical examination to dilated sub-mucosal veins, venules, and overlying mucosalcapillaries [8].A peculiar form of angiodysplastic lesion confinedto the gastric antrum was first described in 1953 byRider et al. and named antral vascular ectasia [9]. Theterm watermelon stomach was coined in 1984 byJabbari, who was struck by its endoscopic features:longitudinal gastric antral folds containing visibleFig. 3. a Microscopic features of WS: gastric antral mucosa withcapillary ectasia focally thrombosed, and b fibromuscular hyperplasiain the lamina propria. by guest on June 5, 2013http://ndt.oxfordjournals.org/Downloaded from Watermelon stomach in the uraemic patient: oestrogen-progesterone therapy 873vessels radiating from the pylorus and resembling theskin of a watermelon [6]. The same lesions of antralvascular ectasia may extend diffusely throughout thegastric antrum, with circumferentially distributed red-dish spots, coalescent in some areas [10]. The twoforms differ only on endoscopic appearances sincehistological aspects are similar. Progression from thelocalized WS aspect to the diffuse form has beenreported [6].Endoscopic diagnosis may prove difficult for aninvestigator unfamiliar with this pattern. On biopsy,however, histological evidence for antral vascular ecta-sia is characteristic, as in our patient : hyperplasticantral mucosa, dilated capillaries in the submucosaand in the lamina propria, some of them with fibrinthrombi, fibromuscular hyperplasia of the muscularismucosae in the lamina propria [6]. The absence ofsigns of gastric inflammation rules out haemorrhagicantritis, a frequent misdiagnosis [11,12]. As biopsycarries only a minimal risk of haemorrhage, it shouldalways be performed.The aetiology of the WS remains obscure. Portalhypertensive mucosal vasculopathy [13], degenerativelesion related to age [14], antral prolapsus [6,14],achlorhydria with hypergastrinaemia [15,16] have allbeen considered.While angiodysplastic lesions are incriminated in1.2-8% of GI tract bleeding episodes in patients withnormal renal function [8], several retrospective reportssuggest that they are responsible for 19-32% of the GItract bleeding episodes observed in patients withchronic renal failure [2-5]. These lesions are locatedmainly in the stomach and the duodenum but thejejunum and the colon can also be affected [2,4,5]. Theactual frequency of antral vacular ectasia andwatermelon stomach in uraemic patients remains to bedetermined. This diagnosis is clearly not unusual: in arecent series of 45 patients with typical WS, six hadchronic renal failure [17].To the best of our knowledge, this is the first reportdemonstrating the beneficial effect of hormone therapyon WS in an uraemic patient. Oestrogen-progesteronetherapy dramatically improved our patients condition:blood transfusions could be interrupted and haemo-globin returned to the target value of lOg/dl withoutsignificant changes in erythropoietin prescription. Norecurrence has been observed 12 months later despitea reduction in oestrogen-progesterone dosage.Interestingly, hormone therapy was first successfullyinitiated in seven uraemic patients with bleeding GIangiodysplastic lesions, four of which being located inthe stomach [18]. Its effectiveness was demonstratedin a double-blind, placebo-controlled, cross-over trialinvolving 10 non-uraemic subjects with chronic haem-orrhage from GI angiodysplastic lesions (7 in thestomach) [19-21]. Successful hormonal treatment ofantral vascular ectasia has recently been reported innon-uraemic patients [22-24]. The mechanism ofaction of this therapy remains unknown. A trophiceffect on the mucosa [25], a primary effect on haemo-stasis [26], on the gastric microcirculation [27] or onoestroprogestative receptors located on vascular ectasia[28] have all been considered.Hormone therapy provides an attractive alternativeto currently available treatments. Antrectomy, indeed,offers definitive cure but carries significant morbidityand an operative mortality of 5-10% [12,16].Conservative treatment with repeated blood transfu-sions, iron replacement, H2 antagonists, sucralfate, orsteroids have all been applied with limited success[6,11,12,14,29]. Although reported to be safe andeffective [17], endoscopic laser coagulation is madedifficult by the diffuse location of the lesions, andrequires repeated sessions [12,14,17].In conclusion, we report an unusual cause of chronicGI haemorrhage in a dialysed patient, the watermelonstomach, and illustrate the long-term therapeutic valueof an oestroprogestative combination.References1. Cunningham JT. Gastric telangiectasias in chronic hemodialysispatients: a report of six cases. Gaslroenterology 1981; 81:1131-11332. Dave PB, Romeu J, Antonelli A, Eiser AR. Gastrointestinaltelangiectasias. A source of bleeding in patients receiving hemod-ialysis. Arch Intern Med 1984; 144: 1781-17833. Zuckerman GR, Cornette GL, Clouse RE, Harter HR. Uppergastrointestinal bleeding in patients with chronic renal failure.Ann Intern Med 1985; 102: 588-5924. Marcuard SP, Weinstock JV. Gastrointestinal angiodysplasia inrenal failure. J Clin Gastroemernl 1988; 10: 482-4845. Clouse RE, Costigan DJ, Millis BA, Zuckerman GR.Angiodysplasia as a cause of upper gastrointestinal bleeding.Arch Intern Med; 145: 458-4616. Jabbari M, Cherry R, Lough JO, Daly DS, Kinnear DG,Goresky CA. Gastric antral vascular ectasia: the watermelonstomach. Gastroenterology 1984; 87: 1165-11707. Boley SJ, Sammartano R, Adams A el al. On the nature andetiology of vascular ectasias of the colon. Degenerative lesionsof aging. Gastroenterology 1977; 72: 650-6608. Foutch PG. Angiodysplasia of the gastrointestinal tract. AmJ Gastroenterol 1993; 88: 807-8189. Rider JA, Klotz AP, Kirsner JB. Gastritis with veno-capillaryectasia as a source of massive gastric hemorrhage.Gastroenterology 1953; 24: 118-12310. Kruger R, Ryan ME, Dickson KB, Nunez JF. Diffuse vascularectasia of the gastric antrum. Am J Gastroenterol 1987; 82:421-42611. Tovey FI. Gastric antral vascular ectasia: The watermelonstomach. Gastroenterology 1985; 88: 129312. Park RHR, Russell RI. Watermelon stomach. Br J Surg 1991;78: 395-39613. Sarfeh IJ, Tarnawski A. Gastric mucosal vasculopathy in portalhypertension. Gastroenterology 1987; 93: 1129-113114. Wesenfelder LJ, Eugene CY. Le watermelon ou estomacpasteque. Line entite mal connue. Gastroenterol Clin Biol 1991;15: 823-82715. Quitero E, Pique JM, Bombi JA el al. Gastric mucosal vascularectasia causing bleeding in cirrhosis: a distinct entity associatedwith hypergastrinemia and low serum levels of pepsinogen 1.Gastroenterology 1987; 93: 1054-106116. Borsch G. Diffuse gastric antral vascular ectasia: the watermelonstomach revisited. Am J Gastroenterol 1987; 82: 1333-133417. Gostout CJ, Viggiano TR, Ahlquist DA el al. The clinical andendoscopic spectrum of the watermelon stomach. J ClinGastroenterol 1992; 15: 256-26318. Bronner MH, Pate MB, Cunnigham JT, Marsh WH.Estrogen-progesterone therapy for bleeding gastrointestinal tel- by guest on June 5, 2013http://ndt.oxfordjournals.org/Downloaded from 874C. Hermans et al.angiectasias in chronic renal failure. Ann Intern Med 1986;105: 371-37419. Van Cutsem E, Rutgeerts P, Vantrappen G. Treatment ofbleeding gastrointestinal vascular malformations with oestrogen--progesterone. Lancet 1990; 335: 953-95520. Van Cutsem E, Rutgeerts P, Vantrappen G et al. Hormonaltherapy for bleeding from angiodysplasia: chronic renal failure.Am J Gastroenterol 1990; 85: 1649-165121. Van Cutsem E, Rutgeerts P, Vantrappen G. Treatment ofbleeding arteriovenous malformations with oral contraceptives:safe sex. Gastroenterology 1991; 101: 263-27022. Moss SF, Ghosh P, Thomas DM, Jackson JE, Calam J. Gastricantral vascular ectasia: maintenance treatment with oestrogen-progesterone. Gut 1992; 33: 715-71723. Manning RJ. Estrogen/progesterone treatment of diffuse antralvascular ectasia. Am J Gastroenterol 1995; 90: 154-15624. Schoonbroodt D, Horsmans Y, Hoang P, Poncelet-Maton E,Laka A, Geubel A. Anomalies vasculaires gastriques, CRESTsyndrome et cirrhose biliaire primitive: efficacite de lassociationethinyloestradiol-norethisterone. Gastroenterol Clin Biol 1994;18: 649-65125. Harrison DFN. Use of estrogen in treatment of familialhemorrhagic telangiectasia. Laryngoscope 1982; 92: 314-31926. Gelfand JA. Exploiting sex for therapeutic purposes. N EnglJ Med 1983; 308: 1417-141927. Panes J, Casadevall M, Fernandes M et al. Gastric microcircula-tory changes of portal-hypertensive rats can be attenuated bylongterm estrogen-progestagen treatment. Hepatology 1994; 20:1261-126928. Li V, Salvat J, Hostein J. Prevention des recidives hemorragiquesde la maladie de Rendu-Osler par traitement oestroprogestatif.Gastroenterol Clin Biol 1992; 16: 29229. Park RHR, Danesh BJZ, Upadhyay R, Howatson AG, Lee FD,Russell RI. Gastric antral vascular ectasia (Watermelon stom-ach)—therapeutic options. Postgrad Med J 1990; 66: 720-723Received for publication: 3.11.95Accepted in revised form: 8 11.95 by guest on June 5, 2013http://ndt.oxfordjournals.org/Downloaded from
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Watermelon stomach An unusual cause of recurrent upper GI tract

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