Clinical Bottom Line

Question	2026 practical answer
What is it?	Gastric antral vascular ectasia. Chronic occult bleeding and iron-deficiency anemia. Overt hematemesis is uncommon.
How does it look?	Longitudinal red stripes to the pylorus (watermelon), diffuse honeycomb, or nodular antral folds. Nodular GAVE is the pattern most often called gastritis.
Not PHG	GAVE is antral. Portal hypertensive gastropathy is fundus and body. Lowering portal pressure does not treat GAVE.
First-line therapy	Endoscopic band ligation has better eradication and less rebleeding than APC in 2025 comparative analyses. APC remains reasonable when banding is not available, especially for flat striped disease.
RFA	Salvage at centers that have it. 2025 CAG guidance suggests against choosing RFA over APC as the default.

What GAVE is

Gastric antral vascular ectasia accounts for a small share of nonvariceal upper GI bleeding, but it is a large share of the transfusion-dependent anemic patient whose "EGD was gastritis." The vessels are mucosal and submucosal ectasias in the antrum. Associated conditions include cirrhosis, systemic sclerosis, chronic kidney disease, and bone-marrow transplant. Heyde syndrome and LVAD shear belong on the same list.

Diagnosis is endoscopic. Biopsy is supportive

Look at the antrum on forward view and on retroflexion. Three patterns: striped/watermelon, diffuse/punctate (more often in cirrhosis), and nodular. Histology, when needed, shows capillary dilation, fibrin thrombi, spindle-cell proliferation, and fibrohyalinosis (Gilliam / GAVE scores). You do not need a biopsy to start treatment when the pattern is classic.

GAVE vs portal hypertensive gastropathy

GAVE: antrum. Stripes, spots, or nodules. May occur without portal hypertension.
PHG: fundus and body. Mosaic or snake-skin mucosa in a patient with portal hypertension.

Beta blockers and TIPS treat PHG bleeding. They do not obliterate GAVE. If you treat antral stripes as PHG, the hemoglobin keeps falling.

Band ligation vs APC vs RFA

APC is still the most widely available tool. It works. It is superficial, often needs several sessions, and rebleeding is common.

A 2025 Gastrointestinal Endoscopy systematic review (10 studies, 476 patients) found EBL superior to APC: eradication 88.6% vs 57.9%, recurrent bleeding 6.6% vs 39.7%, with fewer sessions, transfusions, and hospitalizations. A 2025 network meta-analysis pointed the same way. The 2025 Canadian Association of Gastroenterology guideline on nonvariceal, non-peptic-ulcer upper GI bleeding suggests EBL over APC (conditional, very low certainty) and suggests against choosing RFA over APC as first-line, mainly because of cost and access.

Practical take: nodular GAVE is a banding case. Flat striped disease can still start with APC if that is what the room has. RFA is salvage. Antrectomy is rare and reserved for true endoscopic failure in a patient who can survive surgery.

Selected references

Garg A, Moond V, Bidani K, et al. Endoscopic band ligation versus argon plasma coagulation for GAVE: systematic review and meta-analysis. Gastrointest Endosc. 2025;101:1100-1109.
Gangwani MK, et al. Comparing endoscopic treatment modalities for GAVE: network meta-analysis. J Clin Gastroenterol. 2025;59:555-561.
Canadian Association of Gastroenterology. Clinical Practice Guideline for the Endoscopic Management of Nonvariceal Nonpeptic Ulcer Upper Gastrointestinal Bleeding. Gastroenterology. 2025. Recommendations 10-11.
Fuccio L, et al. Diagnosis and management of gastric antral vascular ectasia. World J Gastrointest Endosc. 2013;5:6-13.

Last reviewed September 20, 2026. Written for clinicians treating transfusion-dependent antral vascular lesions. Local device inventory will decide whether EBL or APC starts the first session.

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