Watermelon Stomach in SSc Common, Linked to Worse Quality of Life

Marta Figueiredo, PhD avatar

by Marta Figueiredo, PhD |

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Watermelon stomach, a condition in which the stomach lining bleeds, is an early and relatively common manifestation of systemic sclerosis (SSc) — especially among patients with diffuse disease — that is associated with worse quality of life, a study in Australia shows.

Officially gastric antral vascular ectasia (GAVE), the condition gets its more colorful name due to the appearance of the stomach lining during endoscopy, when bleeding causes “watermelon stripes” characteristic of the fruit’s exterior.

The new study showed that the presence of self-reactive antibodies against the protein RNA Polymerase III (RNAPIII) appeared to be the main risk factor for GAVE. Following RNAPIII, other risk factors included gastrointestinal (GI) dysmotility — a condition in which the muscles of the digestive system do not work as they should — and digital ulcers, pits, or digital loss.

These findings suggest that watermelon stomach is an underestimated and underappreciated SSc manifestation. Further, using potential risk factors to identify patients at higher risk of this easy-to-treat complication may help improve their lives, the researchers noted.

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The study, “Gastric antral vascular ectasia in systemic sclerosis: a study of its epidemiology, disease characteristics and impact on survival,” was published in the journal Arthritis Research & Therapy.

Also known as scleroderma, systemic sclerosis is an autoimmune disease characterized by extensive blood vessel impairment and tissue scarring. It most often affects the skin, but also may impact several internal organs such as the lungs, kidneys, and GI tract.

It is caused by abnormal immune attacks driven by antibodies that wrongly recognize the body’s own proteins as foreign. These abnormal antibodies are also known as autoantibodies or self-reactive antibodies.

While extensive research has focused on SSc-related blood vessel manifestations, little is known about GAVE, “which is an under-recognized yet treatable SSc vascular [blood vessel] and gastric manifestation,” the researchers wrote.

A rare condition in the general population, GAVE is characterized by small blood vessel abnormalities near the valve connecting the stomach and the small intestine. On endoscopy — a visual scan of the upper digestive system — these abnormalities resemble the stripes on a watermelon, hence the term watermelon stomach.

It is one of the causes of GI bleeding, which can lead to iron deficiency and/or anemia (low red blood cell counts or low levels of hemoglobin).

Now, a team of researchers in Australia set out to describe the frequency of watermelon stomach in SSc patients, as well as its impact on quality of life and survival. Its potential risk factors also were assessed.

The researchers analyzed the demographic and clinical data of 2,039 adults with SSc who enrolled in the Australian Scleroderma Cohort Study, a multicenter study of risk and prognostic factors for clinically important outcomes in SSc.

The data showed that 216 (10.6%) patients had been diagnosed with watermelon stomach over a median follow-up period of 4.3 years (range, 1.7–8.4 years), which is consistent with the frequency rate reported in previous SSc studies (0.6–22.3%).

GAVE was diagnosed at a median age of 55.9. Notably, that diagnosis came after a significantly shorter disease duration in those with diffuse SSc (dSSc) relative to those with limited SSc (3.1 vs 5.3 years).

These findings highlighted that watermelon stomach “is an early SSc disease manifestation (occurring within the first 5 years of disease onset), especially in those with dcSSc,” the researchers wrote.

GAVE was significantly associated with significantly higher rates of hospitalizations (63.4% vs 51.6%) and poorer quality of life, based on the validated 36-Item Short Form Survey, compared with people without GAVE. However, there were no significant survival differences between patients with and without a history of GAVE.

Moreover, patients with GAVE were significantly more likely to have dcSSc (35.3% vs 24.1%) and a history of anemia (38% vs 15.2%), be positive for aRNAPIII autoantibodies (24.9% vs 8.3%), and be negative for anti-Scl-70 and other autoantibodies (4% vs 16.1%) relative to those without this complication.

Significantly higher rates of other blood vessel manifestations also were linked to GAVE. These included fine pink or red spots on the skin, known as telangiectasia, and digital ulcers, pits, and amputations. Also occurring more frequently with GAVE were SSc-related renal crises (SRC) —sudden high blood pressure with kidney and heart failure — and GI involvement such as dysmotility.

When adjusting for potential influencing factors, the team found that the presence of anti-RNAPIII autoantibodies was the most significant independent risk factor for watermelon stomach. In fact, such autoantibodies were associated with a more than threefold higher risk.

Having diffuse SSc, and the presence of SRC, GI dysmotility, and digital ulcers, pits, or amputation also were found to significantly increase the risk of GAVE. Meanwhile, the absence of Scl-70 antibodies had a protective effect.

These findings highlight that GAVE “is an underestimated and underappreciated SSc manifestation of SSc, which occurs with a relatively high frequency,” the researchers wrote.

Since this manifestation “may be mild and not detected clinically,” and endoscopy was only performed when there were signs of potential gastrointestinal involvement, the true frequency of GAVE in these patients “is likely to be an underestimate,” they added.

“Increasing physician awareness as to the presentation and complications of GAVE is an important step in increasing recognition of this disease entity,” the team wrote. “Given GAVE is one of the few SSc manifestations that can be easily and relatively non-invasively diagnosed and treated, perhaps consideration should be given to screening for GAVE in certain at-risk SSc [patients] with 6–12 monthly iron studies and upper gastrointestinal endoscopy in those that are iron deficient.”

This type of approach may help early identification of watermelon stomach in SSc patients, potentially decreasing GAVE-related complications and improving quality of life.