Refractory Duodenal Ulcer and Upper Gastrointestinal Bleeding Following Yttrium-90 Transarterial Radioembolization

Abstract

Abstract Transarterial radioembolization (TARE) with Yttrium-90 (Y90) is widely used for management of primary or secondary liver malignancies that are not amenable to surgery. Nevertheless, complications of Y90 treatment, including rare events of gastric and duodenal ulceration and cirrhosis, may be critical. Here we report a case of a 79-year-old man who received Y90 TARE for metastatic neuroendocrine tumor to liver from bronchial primary and developed multiple iatrogenic GI complications. Following TARE, a gastroduodenal artery (GDA) coil was instituted to prevent migration of Y90 beads. One year following TARE, the patient presented with cirrhosis of unknown etiology, thrombocytopenia, and multiple episodes of upper gastrointestinal bleeding (UGB). Endoscopy demonstrated GDA coil eroding into duodenum through mucosal ulcer base. Three years following TARE, an emergent esophagogastroduodenoscopy was performed due to upper GI bleeding. The histopathologic examination of stomach and duodenum revealed mucosal hemorrhage, submucosal and serosal fibrosis, and chronic inflammation associated with Y90 intravascular beads. A cholecystectomy was performed for fibrotic gallbladder that showed chronic cholecystitis with cholelithiasis and intravascular Y90 beads. GDA coil was removed, which showed attached food material, bacterial colonies, and Candida spp. A subsequent liver biopsy showed previously treated area with Y90 beads, inflammation, and fibrosis in adjacent parenchyma. Due to rich vascularity, TARE is considered an ideal treatment choice for neuroendocrine tumor. GI ulceration is the most common complication, which occurs in less than 4% patients, and usually can be managed with proton pump inhibitor. A surgery should be performed upon failure of medical treatment. Radiation-associated fibrosis has been reported mainly in hepatocellular carcinoma patients, who often have cirrhosis before the procedure. To conclude, this is the first case report of Y90 TARE complications in multiple GI organs in a metastatic NET patient.