Duodenal Ulceration as a Complication of Yttrium-90 Microsphere Radioembolization of Intrahepatic Cholangiocarcinoma

Abstract

Yttrium-90 (Y-90) microsphere radioembolization (RE) can be an effective regional treatment for primary hepatobiliary malignancies. RE with Y-90 has been described as safe for patients with intrahepatic cholangiocarcinoma (ICC)1. However, gastrointestinal ulceration is a rarely reported complication of Y-90 microsphere RE2. Given the increasing incidence of primary hepatobiliary tumors and an expected rise in use of Y-90 RE, we present a case of Y-90 RE-associated duodenal ulceration. A 76-year-old woman presented to the hospital with lower abdominal pain and was evaluated with a CT scan which revealed an ill-defined liver mass adjacent to the gallbladder which was diagnosed as stage IV intrahepatic cholangiocarcinoma involving segment 4 of the liver. She was treated with Y-90 RE with the intent of tumor down-sizing prior to resection. As part of the treatment application, the gastroduodenal artery was densely packed with coils with complete stasis of flow achieved. Through the medial branch of the left hepatic artery, the Y-90 spheres were super-selectively deployed through a micro-catheter. Two months after the radioembolization, she experienced mid-epigastric abdominal pain, not responsive to proton pump inhibitor. Upper endoscopy revealed two non-bleeding superficial duodenal ulcers with no stigmata of bleeding in the duodenal bulb. Pathology from biopsies of the ulcer bed revealed the presence of Y-90 beads in the lamina propria, consistent with radiation-induced duodenitis. She is currently being treated with high dose proton pump inhibitor (PPI) therapy by mouth twice daily, with good response. This case highlights a potential complication associated with radioactive microsphere embolization. Given the increasing use of this treatment modality, gastroenterologists should recognize this entity, and its delayed occurrence in particular. New-onset, or change in abdominal discomfort or pain should prompt endoscopic evaluation in patients with prior Y-90 RE. We suggest high dose PPI therapy as initial management, but the optimal treatment strategy to treat gastrointestinal ulceration as a complication of RE should be further investigated.