Abdom Imaging 20:26-28 (1995) Abdominal Imaging 9 Springer-Verlag New York Inc. 1995 Endoscopic ultrasound appearance of watermelon stomach G. F. Barnard, 1 J. M. Colby, 2 J. R. Saltzman, ~ P. E. Krims, 1 L. Li, ~ B. F. Banner 3 ~Department of Medicine, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA 2Department of Radiology, University of Massachusetts Medical Center, 55 Lake Avenue North, Worchester, MA 01655, USA 3Department of Pathology, University of Massachusetts Medical Center, 55 Lake Avenue North, Worchester, MA 01655, USA Received: 7 September 1993/Accepted: 10 October 1993 Abstract Gastric antral vascular ectasia (GAVE) seen endoscop- ically has characteristic thickened, red vascular folds radiating from the pylorus to the antrum. The endo- scopic ultrasound findings are described and correlated with the visual appearance, computed tomographic (CT) scans, and histologic findings. Hyperechoic focal thick- ening of the inner layers of the gastric wall are noted and may reflect the diagnosis of GAVE. Key words: Stomach--Gastric antral vascular ecta- sia--Watermelon stomach--Endoscopic ultrasound. Case Report A 62-year-old man required transfusion for microcytic anemia and occult blood in the stool attributed to gastritis. Four years later a right hemicolectomy removed a Dukes' C adenocarcinoma. Two subse- quent eolonoscopies and upper endoscopies performed for persistent occult blood in the stool and iron deficiency anemia, revealed only "enlarged gastric folds and antral erosions." Endoscopic biopsies of the stomach revealed gastritis, with no evidence for Helicobacterpy- lori. He was treated with oral iron therapy and sucralfate. When re- evaluated he noted only chronic, mild intermittent abdominal discom- fort, and dark stools since taking oral iron, but no red blood in his stool. He denied nonsteroidal anti-inflammatory agent ingestion. Physical examination revealed a normotensive elderly appearing His- panic male with a pulse rate of 80/min. Examination was notable for a grade II/VI systolic ejection murmur at the left sternal border, a well- healed midline abdominal incision, and guaiac-positive stool. Labo- ratory data revealed a Hct of 28.8%, MCV 85 r, chronically elevated amylase at 273 U/L, a normal lipase and 5' nucleotidase, CEA 2.8 ng/ ml, and AST 74 U/L; PT, PTT, and platelet counts were normal. Gastroscopy revealed markedly abnormal linear erythematous thickened folds, limited to the gastric antrum, and radiating from the Correspondence to: G. F. Barnard pylorus (Fig. 1). The appearance was suggestive of gastric antral vas- cular ectasia (GAVE) or watermelon stomach. Biopsies of these antral friable lesions revealed dilated thrombosed superficial vessels (Fig. 1B), focal fibrosis of the lamina propria, and a mild chronic, active gastritis, and no H. pylori. Gastric body biopsies revealed chronic, active atrophic gastritis. An abdominal computed tomographic (CT) scan was performed to evaluate the distal esophagus and the fiver in the context of mildly elevated liver tests in a patient with a history of colon cancer. It showed a mildly thickened distal esophagus, no lym- phadenopathy, and a thickened prepyloric antrum with a sharp tran- sition to a normal duodenal wall thickness (Fig. 2). To further evaluate the enlarged gastric folds and the thickened distal esophagus, an endoscopic ultrasound (EUS) examination was performed using an Olympus EUM3 sonoendoscope (Olympus, Bur- fington, MA, USA). There were no abnormalities noted during EUS examination of the distal esophagus. Multiple 12.0-MHz images of the antrum and remainder of the stomach were obtained following instillation of degassed water. The proximal stomach appeared nor- real. The antrum, in the region of the endoscopic abnormality, was diffusely abnormal. The wall was thickened measuring upwards of 1 cm at some areas. There was considerable increase in the thickness of the submucosal layer. The mucosal layer was also thickened and had focal regions of hyperechogenicity. The muscularis mucosa was poorly defined in the region of the most marked wall thickening (Fig. 3). Although the interface between the submucosa and muscularis pro- pria was indistinct, the muscularis propria was intact circumferentially and the serosal echo was also maintained. Gastric distensibifity and peristalsis were maintained. Discussion GAVE, or watermelon stomach, first described by Jab- bari et al. [1] in 1984, represents acquired vascular mal- formations of the gastric antrum. The pathogenesis is unknown but ectatic vessels may result from local se- rotoninergic transmitter release [2]. The diagnosis is suggested endoscopically by large linear erythematous folds radiating from the pylorus and involving only the gastric antrum (Fig. 1A). The typical clinical presenta- tion, as in this patient, is of chronic refractory iron de-