3128 A Rare Case of a Gastroduodenal Ulcer Arising From Checkpoint Inhibitors

Abstract

INTRODUCTION: Ipilimumab and Nivolimuab are in a class of immune checkpoint inhibitors that are widely used in the treatment of advanced malignancies. 1 Immunotherapy with monoclonal antibodies targeting cytotoxic T lymphocyte-associated antigen 4 (CTLA4) and the programmed death-1 receptor (PD-1) and its ligand PD-L1 has become the standard of care for cancer treatment today. 1 Gastrointestinal (GI) toxicity from cancer immunotherapy is well described for anti-CTLA4 Abs, but less well studied in combination of anti-CTLA4 and anti-PD-1Abs. GI effects of these immunotherapies range from enterocolitis, pancreatitis, diarrhea, and ulcerations involving the sigmoid colon and rectum. 1 CASE DESCRIPTION/METHODS: Here, we present the case of an 80 year old male with past medical history of renal cell cancer (RCC) that was diagnosed 3 months prior to admission, who presented with melenic stool for one day. The patient had been initiated on a chemotherapy regimen of Ipilimumab and Nivolimuab of which he received three rounds, the last dose one week prior to hospitalization. He had not been on any anticoagulation nor had he endorsed NSAID use. Patient's hemoglobin was closely trended. One day into admission, patient had a large melenic bowel movement with Hb change from 9.0 to 8.7 mg/dL with significant hypotension and tachycardia. Patient was emergently intubated for airway protection for an EGD. EGD revealed a large 4-5 cm ulcer in the second portion of the duodenum and found to have a large artery protruding from the ulcer base, likely the gastroduodenal artery. Endoscopic intervention was performed by placing 5 clips at the ulcer base in an effort to further prevent bleeding. Hemoglobin was trended closely following the procedure, however post-EGD bleeding continued and patient became acutely hypotensive, requiring vasopressor support. As further EGD intervention was considered to be high risk, Interventional Radiology was consulted for embolization with empiric embolization of gastroduodenal artery using a microcoil, which was successful. Hemoglobin continued to trend downwards despite control of bleeding and vasopressor support increased at which point patient was transitioned to comfort measures. DISCUSSION: This case outlines a rare case of immune checkpoint inhibitors as a cause of a gastroduodenal ulcer and the adverse outcomes with checkpoint inhibitors as treatment for malignancies.