Gastric antral vascular ectasia (GAVE) is a rare vascular lesion of the stomach with an overall prevalence of approximately 0.09%, accounting for up to 4% of severe acute gastrointestinal bleeding and 4–6% of non-variceal bleeding in cirrhotic patients. GAVE predominantly affects older adults, with the majority of patients diagnosed at age 60 years or older, and is strongly associated with liver cirrhosis, autoimmune conditions such as systemic sclerosis, and, as increasingly recognized, metabolic syndrome. Three interrelated pathogenic mechanisms have been proposed: mechanical injury from gastric dysmotility, hormonal and vasoactive mediator dysregulation involving hypergastrinemia and prostaglandin E2, and microvascular injury with compensatory neoangiogenesis. Clinically, GAVE most commonly presents as chronic iron deficiency anemia from occult blood loss rather than overt hemorrhage. Endoscopic phenotypes include the classic linear striped “watermelon stomach,” a diffuse punctate or “honeycomb” pattern more commonly seen in cirrhotic patients, and a nodular variant. Distinguishing GAVE from portal hypertensive gastropathy is critical, as their management strategies differ substantially. The histologic triad of vascular ectasia, fibromuscular hyperplasia, and intravascular fibrin thrombi is central to pathologic diagnosis. Intravascular fibrin thrombi, when present, are highly specific for GAVE; CD61 immunohistochemistry serves as a highly useful adjunct in equivocal cases, though its sensitivity is limited by the focal nature of thrombosis and biopsy sampling. Endoscopic therapy remains first-line, with argon plasma coagulation as the most extensively studied modality and radiofrequency ablation demonstrating promising efficacy with potentially lower recurrence rates in preliminary comparative studies. Pharmacologic therapies lack robust evidence, and antrectomy is reserved for refractory cases. This review synthesizes the current understanding of GAVE across its epidemiology, pathogenesis, clinical and endoscopic features, histopathology, differential diagnosis, and management.

This case report reviews a 75-year-old male with several comorbidities who presented with acute encephalopathy and sepsis in the setting of COVID-19 pneumonia, who was noted to have significant gaseous distention of the stomach, emphysematous gastritis (EG), and severe stenosis of the celiac trunk on initial CT imaging. He was treated with empiric IV antibiotics, including ceftriaxone and metronidazole, which were changed to intravenous piperacillin-tazobactam after 24 hours. After being evaluated by surgery and gastroenterology, it was determined that risks outweighed the benefits of EGD and surgical intervention as the patient had a labile hemodynamic status. After extensive goals of care discussions with the patient’s family, he was transitioned to comfort measures only on day 4 of admission and ultimately passed the same day due to cardiopulmonary arrest. EG is often diagnosed late in its course and is associated with extremely high mortality, even with surgical intervention. Evidence from recent case series suggests increasing success with conservative management in selected patients; there are no formal guidelines.

Downhill esophageal varices (DEV) are rare vascular abnormalities of the proximal esophagus, commonly caused by superior vena cava obstruction. We report a 75-year-old man who presented with intermittent dysphagia and globus sensation, in whom endoscopy demonstrated large proximal esophageal varices. Extensive evaluation excluded portal hypertension and cross-sectional imaging, and venography showed a patent superior vena cava and inferior vena cava but demonstrated right internal jugular vein occlusion with possible azygos system compression. These findings were considered remote and insufficient to explain the extensive proximal varices, which were ultimately classified as idiopathic DEV. This atypical presentation underscores the diagnostic challenges of DEV and the need for heightened clinical awareness of this rare entity.