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  • Surgical Pathology Criteria

    Gastric Antral Vascular Ectasia


    • Distinctive pattern of gastric antral vascular changes with an associate distinctive endoscopic appearance

    Alternate/Historical Name

    • Watermelon stomach (from the endoscopic appearance)

    Diagnostic Criteria

    • Mucosal vascular capillary ectasia
      • No vascular malformations
      • Submucosa may have tortuous vessels
    • Fibrin thrombi in capillaries
      • CD61 may be useful to highlight thrombi
    • Edema and hemorrhage
    • Fibromuscular hyperplasia of lamina propria
      • May hyalinize
    • Mild chronic inflammation in lamina propria
      • Atrophic gastritis with intestinal metaplasia frequently present
        • Endocrine cell hyperplasia may be present
    • Microscopic changes may be less spectacular than the endoscopic findings
    • Does not respond to lowering of portal pressure, even if associated with cirrhosis
      • Ablation of vessels may help


    • Predominantly affects adult women
      • Age 40 and older
      • Mean age about 79
    • Presents with iron deficiency anemia
    • Frequently associated with autoimmune disorders and connective tissue diseases
      • Autoimmune atrophic gastritis
      • Hypothyroidism
      • Primary biliary cirrhosis
      • Reynaud phenomenon, sclerodactyly and CREST syndrome
    • Frequently associated with cirrhosis
    • Endoscopic appearance
      • Parallel longitudinal red stripes in antrum converging on pylorus
        • “Watermelon stomach”

    Robert V Rouse MD
    Department of Pathology
    Stanford University School of Medicine
    Stanford CA 94305-5342

    Original posting/updates : 9/9/09, 4/16/10

    Differential Diagnosis

    Portal Hypertensive Gastropathy Gastric Antral Vascular Ectasia
    Involves fundus and corpus Involves antrum
    Endoscopic diffuse changes Endoscopic longitudinal stripes
    Secondary to cirrhosis May be associated with cirrhosis
    No microthrombi Microthrombi characteristic
    No fibromuscular change or hyalinization in lamina propria Fibromuscular hyperplasia with hyalinization of lamina propria

    Atrophic Autoimmune Gastritis Gastric Antral Vascular Ectasia
    Lacks endoscopic stripes Endoscopic watermelon stripes
    Unremarkable capillaries Prominent capillary ectasia
    No microthrombi Microthrombi characteristic
    No fibromuscular change or hyalinization in lamina propria Fibromuscular hyperplasia with hyalinization of lamina propria
    Atrophic autoimmune gastritis may be associated with GAVE, so no features of AAG exclude the diagnosis of GAVE.

    Dieulafoy Lesion / Caliber Persistent Artery Gastric Antral Vascular Ectasia
    Abnormaly large vessel in lamina propria Capillary ectasia and thrombosis in lamina propria
    No specific submucosal lesion Submucosal vessels may be tortuous
    No microthrombi Microthrombi characteristic
    Lamina propria normal except for large vessels Fibromuscular hyperplasia with hyalinization of lamina propria


  • Similar histologic features may be seen in gastric hyperplastic polyps but clinical correlation will avoid any problems
  • Classification / Lists

    Gastritis / Gastropathy


    • Noffsinger A, Fenoglio-Preiser CM, Maru D, Gilinisky N.  Gastrointestinal Diseases, AFIP Atlas of Nontumor Pathology, First Series, Fascicle 5, 2007.
    • Suit PF, Petras RE, Bauer TW, Petrini JL Jr. Gastric antral vascular ectasia. A histologic and morphometric study of "the watermelon stomach". Am J Surg Pathol. 1987 Oct;11(10):750-7.
    • Jabbari M, Cherry R, Lough JO, Daly DS, Kinnear DG, Goresky CA. Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology. 1984 Nov;87(5):1165-70.
    • Vesoulis Z, Naik N, Maseelall P. Histopathologic changes are not specific for diagnosis of gastric antral vascular ectasia (GAVE) syndrome: a review of the pathogenesis and a comparative image analysis morphometric study of GAVE syndrome and gastric hyperplastic polyps. Am J Clin Pathol. 1998 May;109(5):558-64.
    • Gretz JE, Achem SR. The watermelon stomach: clinical presentation, diagnosis, and treatment. Am J Gastroenterol. 1998 Jun;93(6):890-5.
    • Srivastava A, Lauwers GY. Pathology of non-infective gastritis.Histopathology. 2007 Jan;50(1):15-29.
    • Westerhoff M, Tretiakova M, Hovan L, Miller J, Noffsinger A, Hart J. CD61, CD31, and CD34 improve diagnostic accuracy in gastric antral vascular ectasia and portal hypertensive gastropathy: An immunohistochemical and digital morphometric study. Am J Surg Pathol. 2010 Apr;34(4):494-501.
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