Clinical Challenges and Images in GI

Abstract

Question: A 50-year-old woman with a past medical history of chronic hepatitis B complicated by cirrhosis and grade 1 esophageal varices was diagnosed with multifocal hepatocellular carcinoma with the largest lesion being a 3.8 × 3.4 cm mass in the left lobe of the liver. She was deemed not to be a liver transplant candidate. Approximately 1 month after diagnosis, she had initial treatment using radioembolization with yttrium-90 glass microspheres into the left hepatic artery distribution. At 1 month follow-up, the tumor in the left lobe seemed to be responding to treatment as judged by a decrease in tumor size and vascularity. Three months after initial treatment, a second radioembolization was performed to the right hepatic artery distribution for multiple nodules in the right lobe. Three days after the second yttrium-90 glass microspheres administration, the patient presented with severe upper abdominal pain and nausea. Physical examination revealed right upper quadrant tenderness. Laboratory tests showed abnormal liver tests including total bilirubin 1.6 mg/dL (normal, 0.1–1.0); alanine aminotransferase, 52 U/l (normal, 7–45); aspartate aminotransferase, 97 U/L (normal, 8–43); alkaline phosphatase 133 U/L (normal, 39–100); albumin, 2.5 g/dL (normal, 3.5–5.0); and platelets 84 × 109/L (normal, 150–450). The hemoglobin was 10.6 g/dL (normal, 12.0–15.5) and white blood cell count was 3.3 × 109 (normal, 3.5–10.5). A selected slice from her abdominal computed tomography scan is shown (Figure A). What is the cause for her abdominal pain? How should she be managed? Look on page 328 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The CT scan of the abdomen shows thickening of the gallbladder wall with significant pericholecystic fluid (Figure B). There were no signs of air in the gallbladder wall and no evidence of perforation. The patient was managed conservatively with intravenous antibiotics. She improved progressively and was discharged 7 days after admission. A follow-up CT scan performed 6 weeks later showed a substantial decrease in the gallbladder size, wall thickening and pericholecystic fluid (Figure C).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Radioembolization with yttrium-90 glass microspheres is an emerging locoregional treatment for unresectable hepatocellular carcinoma. Common side effects include fatigue, transient elevation of liver enzymes,1Carr B.I. Hepatic arterial 90yttrium glass microspheres (TheraSphere) for unresectable hepatocellular carcinoma: interim safety and survival data in 65 patients.Liver Transpl. 2004; 10: S107-S110Crossref PubMed Scopus (219) Google Scholar and anorexia. Rare side effects include radiation hepatitis, pneumonitis, gastritis, and cholecystitis.2Salem R. Thurston K.G. Radioembolization with 90yttrium microspheres: a state-of-the-art brachytherapy treatment for primary and secondary liver malignancies Part 2: special topics.J Vasc Interv Radiol. 2006; 17: 1425-1439Abstract Full Text Full Text PDF PubMed Scopus (175) Google Scholar Most patients who develop cholecystitis after radioembolization have had the treatment applied to the right hepatic artery distribution. In the majority of individuals, the cystic artery arises from the right hepatic artery; consequently, the inadvertent infusion of radioactive microspheres into the cystic artery during radioembolization can cause radiation effects on the gallbladder, leading to cholecystitis. Although most patients are managed conservatively, there are a few patients who require emergent cholecystectomy.