Massive Gastric Necrosis Following Chemoembolization for Hepatocellular Carcinoma

Abstract

Purpose: Severe gastric necrosis due to trans arterial chemoembolization (TACE) for HCC has not been previously described to our knowledge. Methods: Presentation: A 72 yr old man with HCC presented with chest and abdominal discomfort and melena 4 days after undergoing TACE for hepatocellular carcinoma. He was pale but not febrile or orthostatic. Cardiac and abdominal exam was non focal. Rectal exam revealed melenic stool. The hemoglobin had decreased from 13 to 10gm/dL. Results: Diagnosis: Urgent EGD revealed giant, non bleeding, cratered gastric ulcers, with pigmented material, on the lesser curvature, incisura and posterior wall of the stomach. Biopsies showed extensive necrotic tissue with no malignancy. Abdominal MRI revealed a 5.2 cm mass in the left hepatic lobe similar to pre-chemoembolization images. No free air was seen. Review of the angiography at TACE revealed an aberrant take-off of the left gastric artery from the common hepatic artery, not the celiac artery. This resulted in inadvertent delivery of the chemotherapeutic agent via the left gastric artery to the lesser curvature of the stomach. Management: The patient was made NPO, treated with high dose PPIs, IV antibiotics, and monitored closely for gastric perforation. He did well on conservative therapy and was discharged on PPIs. Serial endoscopy 1 month and 4 months later documented progressive healing of the necrotic area. Conclusions: TACE is an increasingly used therapy for patients with HCC. Common side effects are fever, pain, increased serum amylase and transaminase levels. A 5% incidence of non-variceal bleeding after TACE has been reported (1). Gastric necrosis is a previously unreported complication of TACE with potentially significant clinical impact. Aberrant take-offs are a common occurrence (10–40%) in the mesenteric arterial system and physicians should be aware of potential vascular anomalies and use selective cannulization during chemoembolization to prevent gastrointestinal necrosis. Gastrointestinal bleeding after hepatic transcatheter arterial embolization in patients with hepatocellular carcinoma. GIE 1996; 43 (2)132–137