Bruce
MD
A. Urban,
Scott
E Kern,
#{149} Bronwyn
MD
Jones,
FRACP,
J. Ravich,
#{149} William
FRCR
#{149} Elliot
Index ach, 723.299
terms:
Stomach,
hemorrhage, #{149} Stomach,
CT,
723.299 antral
723.1211 Stomach,
per endoscopy tively bleeding
G
antral
ectasia,
vascular
ectasia,
to the stripes
or
on a watermelon
rind. We present the findings from computed tomography (CT), upper gastrointestinal series, and specimen radiognaphy in a patient with gastric antral vascular ectasia. To our knowledge, this entity has not been reported previously in the radiology literature.
CASE A 74-year-old with melena.
were itive.
Hispanic
negative, Gastric
compatible complete
From
presented
of fatigue
examination
and
results
but stools were guaiac analysis with pentagastrmn revealed
basal,
peak,
pos-
and
acid
output values of 0 mEq/hr, with gastric achlorhydria. A blood count revealed anemia
(hemoglobin,
persisted
man
history
Physical
stimulation maximal
1
REPORT
a several-year
5 g/dL
despite
the
Russell
[50
g/L]),
transfusions
H. Morgan
which
and
revealed antral
thick, friable, folds radiating
sphincter
ectasia marked
(Fig
acto
3). Biopsy
(Fig
4a). foveolar
The
of
mucosa hyperplasia,
tient’s
anemia
of
Radiology and Radiological Science (B.A.U., B.J., E.K.F.), the Department of Pathology (S.E.K.), and the Division of Gastroenterology, Department of Medicine (W.J.R.), The Johns Hopkins University School of Medicine, 600 N Wolfe St. Baltimore, MD 21205. Received June 26, 1990; revision requested July 27; revision received September 12; accepted September 19. Address reprint requests to B.J. a RSNA, 1991
3 months
later
dem-
(hemoglo-
bin, 12.3 g/dL [123 g/L]). amination of the resected
Pathologic specimen
vealed
antrum,
a contracted
bunching
of mucosa
nent
(Fig
folds
distal
producing
4c).
exre-
with promi-
Specimen
radiography
helped confirm thickening of the folds and the antral wall (Fig 4d). Postoperative complications of outlet obstruction secondary to anastomotic ulceration and be-
zoar formation partial with
were
gastrectomy no evidence
treated
several of recurrent
with
further
months later, vascular
ectasia.
sa, with secondary reactive muscular hyperplasia and ectasia of the mucosal vessels (2). Antral hypercontractility, primary or acquired, may induce prolapse. Some authors have likened this entity to solitary rectal ulcer syndrome,
a condition
in which
is believed Thrombosed
to play ectatic
mucosal
prolapse
a causative vessels,
role. however,
are seen only in gastric antral vascular ectasia and are a distinctive feature (5). Gastric ily
antral
affects
vascular
women
ectasia
(9:1
priman-
female-to-male
ratio) aged 56-76 years, and is associated with liver cirrhosis (37%) and achlorhydnia (35%) (6). The usual symptoms are iron-deficiency anemia and melena due to chronic gastrointestinal bleeding from the dilated, superficial, and easily traumatized vessels (2). Antrectomy is curative, but endoscopic treatment with heat probes or lasers has shown promise (1,3,7-9). Upper gastrointestinal series have
been
mentioned
in only
eight
cases
the literature (8-12). One patient onstrated prominent antral folds as did the patient reported here; had intermittent prolapse of the antrum (9); the others had normal ings. Angiographic results were
in
dem(12), one gastric findmen-
tioned in four cases, and no evidence of macroscopic collateral circulation was seen entity
DISCUSSION
(1,2,4). have,
CT abnormalities to our knowledge,
of this not
Although recognized pathologically as a rare source of potential gastrointestinal hemorrhage as early as the 1950s,
been described previously. The relative lack of radiographic findings in most cases suggests that detectable abnon-
gastric antnal vascular ectasia has only recently been characterized with the
malities may be limited to those tients with extensive changes.
advent of modern endoscopy. This syndrome was first recognized endoscopically by Wheeler et al in 1979 (1), and the term “watermelon stomach” was coined by Jabbari et al in 1984 (2). Up
nent mucosal folds extending from the pylonic channel on upper gastrointestinal series and the thickened antral wall on CT scans correlate well with the
to the time
known
ly 40
iron
Department
antrum,
with extension of smooth muscle fibers from the muscularis mucosa into the lamma propria (Fig 4b). Antrectomy and vagotomy with Billroth I anastomosis were performed, with resolution of the pa-
“watermelon stomach,” is a rare cause of chronic gastrointestinal bleeding, characterized endoscopically by a distinctive appearance of prominent red vascular folds traversing the gastric antrum and radiating to the pylomic sphincter; this appearance has been lik-
ened
pyloric
vascular onstrated
1991; 178:517-518
ASTRIC
upper
demonstrated folds in the
the antral folds revealed thrombosed, dilated capillaries at the apices of the folds, the diagnostic feature of gastric antral
723.299
Radiology
series scalloped
radiating to the pyboric sphincter and suggesting antral gastritis (Fig 1). CT demonstrated focal 1-cm thickening of the gastric wall in the antrum (Fig 2). Up-
mucosa,
#{149}
vascular
A double-contrast
gastrointestinal prominent,
#{149} Stom-
#{149}
Ectasia
supplements.
the
MD
MD
Gastric Antral Vascular (‘ ‘ Watermelon Stomach”): Radiologic Findings’ Radiologic findings in a patient with gastric antral vascular ectasia are described on computed tomographic scans, upper gastrointestinal series, and specimen radiographs. Findings include prominent, scalloped antral folds radiating to the pylorus and thickening of the gastric antrum. Pathognomonic red vascular folds, likened to stripes on a watermelon, can be seen endoscopically.
K. Fishman,
patients
of this with
report, this
approximateendoscopic
di-
In our patient,
agnosis had been reported in the literatune. The appearance of longitudinal hypertrophic folds containing red columns of dilated blood vessels is characteristic. Pathognomonic histologic features include foveolan hyperplasia,
ly,
vascular muscular
scopically
the
lamina
ectasia with clots, and spindle cell hyperplasia propria
(2-4).
fibroof
changes
are believed
petitive prolapse
low-grade trauma due of the loosely attached
to result
from
antral
me-
to repeat muco-
vascular
of promi-
appearance ectasia.
thickening
results
of gasHistologicalfrom a
combination of foveolar and fibromuscular hyperplasia. Grossly, the antral fold prominence bunching of the
ened, confined
These
pathologic
tnic antral
the findings
pa-
appears mucosa
hypercontractile visible
to result from in the thick-
antrum. vascular
to the apices
Endo-
ectasia
of the folds,
is
a me-
suit of repetitive trauma to the surface mucosa of the distal antmum, probably due to pyloric prolapse. The radiographic differential diagnosis includes
517
I.
3.
2.
(1) Spot
1-3.
Figures (arrows)
radiating
in
radiograph a linear
(3) Endoscopic appearance stripes on a watermelon
Figure
4.
(a) Biopsy
shows distinctive sal vessel (arrow) original
fashion
to
the
of the gastric rind.
specimen
X600).
(b)
antrum
pylonic
from
channel.
antrum.
of antral
thrombosed ectatic (hematoxylmn-eosin
magnification,
tative trum.
of the gastric
Linear
streaks
double-contrast upper gastrointestinal series (2) CT scan shows moderate focal thickening of erythematous
folds
radiating
to the
reveals
prominent
of the gastric pyloric channel
antrum (arrow)
gastric
folds
(arrow). are likened
to
fold
mucostain;
Represen-
photomicrograph of the gastric anThe gastric foveolae are elongated and
villiform (arrowheads), and smooth muscle fibers are present in the bamina pnopria (an-
rows) (hematoxylin-eosin stain; original magnification, X100). (c) Gross cross section of the antrum shows folding of the mucosa into
prominent
specimen
rugae.
radiograph,
with heavy-density ing of the gastric
scalloped,
(d) Postoperative with mucosa barium, reveals antral wall (arrow)
prominent
gastric
folds
coated thickenand
(arrow-
heads).
gastritis and, less commonly, vanices or anteniovenous malformation (13). Prominent antral folds and antral thickening in the elderly patient with
chronic
anemia
should
alert
a.
b.
the radiol-
ogist to the possibility of gastric antral vascular ectasia. This entity can then be confirmed endoscopically. Surgery may be indicated in patients with severe recurrent bleeding and is curative. U
References 1.
2.
Wheeler
MH,
Smith
PM,
Cotton
DM. Lawnie BW. the gastric antrum:
Abnormal a cause
intestinal 158. Jabbari
R, Lough
bleeding.
Dig
M, Cheery
PB, Evans
blood vessels in for upper gastro-
Dis
Sd
1979;
24:155-
JO.
Daly
DS,
Kin-
near DC, Goresky CA. Gastric antral vasculan ectasia: the watermelon stomach. Castroenterology 1984; 87:1165-1170. 3.
Kruger
R, Ryan
Diffuse vascular Am J Gastroenterol 4.
5.
6.
518
Suit
PF,
Petras
ME,
Dickson
KB, Nunez
ectasia of the gastric 1987; 82:421-426. RE, Bauer
TW,
Petrini
JF.
antrum. JL.
Radiology
7.
Petnini
JL Jr. Johnston
ment for Endoscopy
Gas-
tric antral vascular ectasia: a histologic and morphometnic study of “the watermelon stomach.” Am J Sung Pathol 1987; 11:750-775. DuBoulay C, Fairbrother 1. Isaacson PG. Mucosal prolapse syndrome: a unifying concept for solitary ulcer syndrome and related disordens. J Clin Pathol 1983; 36:1264-1268. Borsch C. Diffuse gastric antral vascular ectasia: the “watermelon stomach” revisited (letter). Am J Gastroenterol 1987; 82:13331334.
#{149}
d.
C.
8. 9.
10.
Rawlinson
JH.
Heat
antral vascular ectasia. 1989; 35:324-328.
WD,
probe
treat-
Barr GD, Lin BP.
Antral
vas-
cular ectasia: the “watermelon” stomach. Med J Aust 1986; 144:709-711. Frager JD, Brandt U, Frank MS. Morecki R. Treatment of a patient with watermelon stomach using transendoscopic laser photocoagulation. Gastrointest Endoscopy 1988; 34:134-137. Tovey Fl. Gastric antral vascular ectasia: the
watermelon ogy
stomach
(letter).
1 1.
Gastrointest
12.
Cabam 1. Walker RJ. Antral vascular lesion, achlorhydria. and chronic gastrointestinal blood loss: response to steroids. Dig Dis Sd 1980; 25:236-239. Gardiner GW, Murray D, Prokipchuk EJ. Watermelon stomach, or antral gastritis (let-
ter). J Clin 13.
Pathob
1985; 38:1317-1318.
Lewis TD, Laufer I, Goodacre RL. Arteniovenous malformation of the stomach: radiobogic and endoscopic features. Am J Dig Dis 1978; 23:467-471.
Gastroenterol-
1985; 88:1293.
February
1991
MD
A. Urban,
Scott
E Kern,
#{149} Bronwyn
MD
Jones,
FRACP,
J. Ravich,
#{149} William
FRCR
#{149} Elliot
Index ach, 723.299
terms:
Stomach,
hemorrhage, #{149} Stomach,
CT,
723.299 antral
723.1211 Stomach,
per endoscopy tively bleeding
G
antral
ectasia,
vascular
ectasia,
to the stripes
or
on a watermelon
rind. We present the findings from computed tomography (CT), upper gastrointestinal series, and specimen radiognaphy in a patient with gastric antral vascular ectasia. To our knowledge, this entity has not been reported previously in the radiology literature.
CASE A 74-year-old with melena.
were itive.
Hispanic
negative, Gastric
compatible complete
From
presented
of fatigue
examination
and
results
but stools were guaiac analysis with pentagastrmn revealed
basal,
peak,
pos-
and
acid
output values of 0 mEq/hr, with gastric achlorhydria. A blood count revealed anemia
(hemoglobin,
persisted
man
history
Physical
stimulation maximal
1
REPORT
a several-year
5 g/dL
despite
the
Russell
[50
g/L]),
transfusions
H. Morgan
which
and
revealed antral
thick, friable, folds radiating
sphincter
ectasia marked
(Fig
acto
3). Biopsy
(Fig
4a). foveolar
The
of
mucosa hyperplasia,
tient’s
anemia
of
Radiology and Radiological Science (B.A.U., B.J., E.K.F.), the Department of Pathology (S.E.K.), and the Division of Gastroenterology, Department of Medicine (W.J.R.), The Johns Hopkins University School of Medicine, 600 N Wolfe St. Baltimore, MD 21205. Received June 26, 1990; revision requested July 27; revision received September 12; accepted September 19. Address reprint requests to B.J. a RSNA, 1991
3 months
later
dem-
(hemoglo-
bin, 12.3 g/dL [123 g/L]). amination of the resected
Pathologic specimen
vealed
antrum,
a contracted
bunching
of mucosa
nent
(Fig
folds
distal
producing
4c).
exre-
with promi-
Specimen
radiography
helped confirm thickening of the folds and the antral wall (Fig 4d). Postoperative complications of outlet obstruction secondary to anastomotic ulceration and be-
zoar formation partial with
were
gastrectomy no evidence
treated
several of recurrent
with
further
months later, vascular
ectasia.
sa, with secondary reactive muscular hyperplasia and ectasia of the mucosal vessels (2). Antral hypercontractility, primary or acquired, may induce prolapse. Some authors have likened this entity to solitary rectal ulcer syndrome,
a condition
in which
is believed Thrombosed
to play ectatic
mucosal
prolapse
a causative vessels,
role. however,
are seen only in gastric antral vascular ectasia and are a distinctive feature (5). Gastric ily
antral
affects
vascular
women
ectasia
(9:1
priman-
female-to-male
ratio) aged 56-76 years, and is associated with liver cirrhosis (37%) and achlorhydnia (35%) (6). The usual symptoms are iron-deficiency anemia and melena due to chronic gastrointestinal bleeding from the dilated, superficial, and easily traumatized vessels (2). Antrectomy is curative, but endoscopic treatment with heat probes or lasers has shown promise (1,3,7-9). Upper gastrointestinal series have
been
mentioned
in only
eight
cases
the literature (8-12). One patient onstrated prominent antral folds as did the patient reported here; had intermittent prolapse of the antrum (9); the others had normal ings. Angiographic results were
in
dem(12), one gastric findmen-
tioned in four cases, and no evidence of macroscopic collateral circulation was seen entity
DISCUSSION
(1,2,4). have,
CT abnormalities to our knowledge,
of this not
Although recognized pathologically as a rare source of potential gastrointestinal hemorrhage as early as the 1950s,
been described previously. The relative lack of radiographic findings in most cases suggests that detectable abnon-
gastric antnal vascular ectasia has only recently been characterized with the
malities may be limited to those tients with extensive changes.
advent of modern endoscopy. This syndrome was first recognized endoscopically by Wheeler et al in 1979 (1), and the term “watermelon stomach” was coined by Jabbari et al in 1984 (2). Up
nent mucosal folds extending from the pylonic channel on upper gastrointestinal series and the thickened antral wall on CT scans correlate well with the
to the time
known
ly 40
iron
Department
antrum,
with extension of smooth muscle fibers from the muscularis mucosa into the lamma propria (Fig 4b). Antrectomy and vagotomy with Billroth I anastomosis were performed, with resolution of the pa-
“watermelon stomach,” is a rare cause of chronic gastrointestinal bleeding, characterized endoscopically by a distinctive appearance of prominent red vascular folds traversing the gastric antrum and radiating to the pylomic sphincter; this appearance has been lik-
ened
pyloric
vascular onstrated
1991; 178:517-518
ASTRIC
upper
demonstrated folds in the
the antral folds revealed thrombosed, dilated capillaries at the apices of the folds, the diagnostic feature of gastric antral
723.299
Radiology
series scalloped
radiating to the pyboric sphincter and suggesting antral gastritis (Fig 1). CT demonstrated focal 1-cm thickening of the gastric wall in the antrum (Fig 2). Up-
mucosa,
#{149}
vascular
A double-contrast
gastrointestinal prominent,
#{149} Stom-
#{149}
Ectasia
supplements.
the
MD
MD
Gastric Antral Vascular (‘ ‘ Watermelon Stomach”): Radiologic Findings’ Radiologic findings in a patient with gastric antral vascular ectasia are described on computed tomographic scans, upper gastrointestinal series, and specimen radiographs. Findings include prominent, scalloped antral folds radiating to the pylorus and thickening of the gastric antrum. Pathognomonic red vascular folds, likened to stripes on a watermelon, can be seen endoscopically.
K. Fishman,
patients
of this with
report, this
approximateendoscopic
di-
In our patient,
agnosis had been reported in the literatune. The appearance of longitudinal hypertrophic folds containing red columns of dilated blood vessels is characteristic. Pathognomonic histologic features include foveolan hyperplasia,
ly,
vascular muscular
scopically
the
lamina
ectasia with clots, and spindle cell hyperplasia propria
(2-4).
fibroof
changes
are believed
petitive prolapse
low-grade trauma due of the loosely attached
to result
from
antral
me-
to repeat muco-
vascular
of promi-
appearance ectasia.
thickening
results
of gasHistologicalfrom a
combination of foveolar and fibromuscular hyperplasia. Grossly, the antral fold prominence bunching of the
ened, confined
These
pathologic
tnic antral
the findings
pa-
appears mucosa
hypercontractile visible
to result from in the thick-
antrum. vascular
to the apices
Endo-
ectasia
of the folds,
is
a me-
suit of repetitive trauma to the surface mucosa of the distal antmum, probably due to pyloric prolapse. The radiographic differential diagnosis includes
517
I.
3.
2.
(1) Spot
1-3.
Figures (arrows)
radiating
in
radiograph a linear
(3) Endoscopic appearance stripes on a watermelon
Figure
4.
(a) Biopsy
shows distinctive sal vessel (arrow) original
fashion
to
the
of the gastric rind.
specimen
X600).
(b)
antrum
pylonic
from
channel.
antrum.
of antral
thrombosed ectatic (hematoxylmn-eosin
magnification,
tative trum.
of the gastric
Linear
streaks
double-contrast upper gastrointestinal series (2) CT scan shows moderate focal thickening of erythematous
folds
radiating
to the
reveals
prominent
of the gastric pyloric channel
antrum (arrow)
gastric
folds
(arrow). are likened
to
fold
mucostain;
Represen-
photomicrograph of the gastric anThe gastric foveolae are elongated and
villiform (arrowheads), and smooth muscle fibers are present in the bamina pnopria (an-
rows) (hematoxylin-eosin stain; original magnification, X100). (c) Gross cross section of the antrum shows folding of the mucosa into
prominent
specimen
rugae.
radiograph,
with heavy-density ing of the gastric
scalloped,
(d) Postoperative with mucosa barium, reveals antral wall (arrow)
prominent
gastric
folds
coated thickenand
(arrow-
heads).
gastritis and, less commonly, vanices or anteniovenous malformation (13). Prominent antral folds and antral thickening in the elderly patient with
chronic
anemia
should
alert
a.
b.
the radiol-
ogist to the possibility of gastric antral vascular ectasia. This entity can then be confirmed endoscopically. Surgery may be indicated in patients with severe recurrent bleeding and is curative. U
References 1.
2.
Wheeler
MH,
Smith
PM,
Cotton
DM. Lawnie BW. the gastric antrum:
Abnormal a cause
intestinal 158. Jabbari
R, Lough
bleeding.
Dig
M, Cheery
PB, Evans
blood vessels in for upper gastro-
Dis
Sd
1979;
24:155-
JO.
Daly
DS,
Kin-
near DC, Goresky CA. Gastric antral vasculan ectasia: the watermelon stomach. Castroenterology 1984; 87:1165-1170. 3.
Kruger
R, Ryan
Diffuse vascular Am J Gastroenterol 4.
5.
6.
518
Suit
PF,
Petras
ME,
Dickson
KB, Nunez
ectasia of the gastric 1987; 82:421-426. RE, Bauer
TW,
Petrini
JF.
antrum. JL.
Radiology
7.
Petnini
JL Jr. Johnston
ment for Endoscopy
Gas-
tric antral vascular ectasia: a histologic and morphometnic study of “the watermelon stomach.” Am J Sung Pathol 1987; 11:750-775. DuBoulay C, Fairbrother 1. Isaacson PG. Mucosal prolapse syndrome: a unifying concept for solitary ulcer syndrome and related disordens. J Clin Pathol 1983; 36:1264-1268. Borsch C. Diffuse gastric antral vascular ectasia: the “watermelon stomach” revisited (letter). Am J Gastroenterol 1987; 82:13331334.
#{149}
d.
C.
8. 9.
10.
Rawlinson
JH.
Heat
antral vascular ectasia. 1989; 35:324-328.
WD,
probe
treat-
Barr GD, Lin BP.
Antral
vas-
cular ectasia: the “watermelon” stomach. Med J Aust 1986; 144:709-711. Frager JD, Brandt U, Frank MS. Morecki R. Treatment of a patient with watermelon stomach using transendoscopic laser photocoagulation. Gastrointest Endoscopy 1988; 34:134-137. Tovey Fl. Gastric antral vascular ectasia: the
watermelon ogy
stomach
(letter).
1 1.
Gastrointest
12.
Cabam 1. Walker RJ. Antral vascular lesion, achlorhydria. and chronic gastrointestinal blood loss: response to steroids. Dig Dis Sd 1980; 25:236-239. Gardiner GW, Murray D, Prokipchuk EJ. Watermelon stomach, or antral gastritis (let-
ter). J Clin 13.
Pathob
1985; 38:1317-1318.
Lewis TD, Laufer I, Goodacre RL. Arteniovenous malformation of the stomach: radiobogic and endoscopic features. Am J Dig Dis 1978; 23:467-471.
Gastroenterol-
1985; 88:1293.
February
1991
