Why GIVE a Liver Why GIVE a Liver Transplant to Patients Transplant to Patients with GAVE Syndromewith GAVE Syndrome

GAVEGAVEGastric Antral Vascular Ectasia

Incidence and EtiologyIncidence and Etiology

More common in females (ratio reversed in More common in females (ratio reversed in cirrhotic population)cirrhotic population)

Elderly-70’sElderly-70’s 30% of patients diagnosed also have cirrhosis30% of patients diagnosed also have cirrhosis Other 70% associated with autoimmune Other 70% associated with autoimmune

diseasesdiseases 5.7% of all sclerosis patients5.7% of all sclerosis patients

Etiology commonly thought to be related to Etiology commonly thought to be related to abnormal antral motility and mucosal atrophyabnormal antral motility and mucosal atrophy

GAVE vs PHGGAVE vs PHG

Diagnosis and SymptomsDiagnosis and Symptoms GAVEGAVE

lesions are restricted to antrum, diffuse or linearlesions are restricted to antrum, diffuse or linear chronic significant blood loss often resulting in transfusion dependencychronic significant blood loss often resulting in transfusion dependency Only 4% of acute GI bleeds are attributable to GAVE syndromeOnly 4% of acute GI bleeds are attributable to GAVE syndrome

Portal Hypertensive Gastropathy (PHG)Portal Hypertensive Gastropathy (PHG) lesions throughout, lesions are diffuselesions throughout, lesions are diffuse

TreatmentTreatment PHG- responds to portal pressure reduction effortsPHG- responds to portal pressure reduction efforts

Beta-blockerBeta-blocker TIPS-Transjugular Intrahepatic Portosystemic ShuntTIPS-Transjugular Intrahepatic Portosystemic Shunt

GAVEGAVE Estrogen-ProgesteroneEstrogen-Progesterone Endoscopic Argon Plasma Coagulation (APC)Endoscopic Argon Plasma Coagulation (APC) Antrectomy- high mortality in cirrhotic patientsAntrectomy- high mortality in cirrhotic patients Liver Transplant Liver Transplant

Liver Transplant for GAVELiver Transplant for GAVE

Study out of Mayo Clinic in Jacksonville FLStudy out of Mayo Clinic in Jacksonville FL reviewed 597 patients transplanted from February reviewed 597 patients transplanted from February

1998 to June 2003.1998 to June 2003. 345 had EGD prior to OLT, 8 (2.3%) had GAVE 345 had EGD prior to OLT, 8 (2.3%) had GAVE

pre OLTpre OLT 3 of 8 had post OLT EGD, GAVE absent in all 3, 3 of 8 had post OLT EGD, GAVE absent in all 3,

other 5 had no post OLT gastrointestinal bleedingother 5 had no post OLT gastrointestinal bleeding

J Clin Gatroenterol. 2004. Ward EM et alJ Clin Gatroenterol. 2004. Ward EM et al

Patient DemographicsPatient Demographics

49 y/o F49 y/o F Cirrhosis secondary to NASH (Non-alcoholic Cirrhosis secondary to NASH (Non-alcoholic

steatohepatitissteatohepatitis Portal hypertensionPortal hypertension Hepatic EncephalopathyHepatic Encephalopathy GAVE syndromeGAVE syndrome

Clinical DataClinical Data

LabsLabs Total Bilirubin 0.9-2.0Total Bilirubin 0.9-2.0 INR 1.4-1.8INR 1.4-1.8 Creatinine 1.2-2.4Creatinine 1.2-2.4 Albumin 2.9Albumin 2.9 Sodium 130’sSodium 130’s Platelets 40’sPlatelets 40’s Hemoglobin 6.0-9.5Hemoglobin 6.0-9.5

InterventionsInterventions H/H checks 2x/week, H/H checks 2x/week,

scheduled outpatient scheduled outpatient transfusionstransfusions

PRBCs greater than 60 PRBCs greater than 60 Units over 8 monthsUnits over 8 months

APC- 7 treatmentsAPC- 7 treatments 29 Hospitalizations in 1 29 Hospitalizations in 1

years time-10 for years time-10 for GIB/anemiaGIB/anemia

UNOS MELD exception requestUNOS MELD exception request

MELD 15-25MELD 15-25 Higher MELDs driven by AKI/HRSHigher MELDs driven by AKI/HRS MELD exception request denied for:MELD exception request denied for:

No increased mortalityNo increased mortality Try APCTry APC Recommend live liver donorRecommend live liver donor Not appropriate diagnosis for MELD exceptionNot appropriate diagnosis for MELD exception

Patient UpdatePatient Update

Patient recently transplantedPatient recently transplanted Post OLT course has been quite complicated Post OLT course has been quite complicated

but no gastrointestinal bleedingbut no gastrointestinal bleeding Has not had EGD post OLT to confirm Has not had EGD post OLT to confirm

resolutionresolution

Nursing ImplicationsNursing Implications

Correct diagnosis is key for treatmentCorrect diagnosis is key for treatment Educating the patient and other care givers Educating the patient and other care givers

about GAVE syndromeabout GAVE syndrome Scheduling of serial H/H checks, transfusions, Scheduling of serial H/H checks, transfusions,

Endoscopic APCEndoscopic APC Resolves with Liver Transplantation though Resolves with Liver Transplantation though

exact mechanism is unknownexact mechanism is unknown