Transarterial Chemoembolization (TACE) Leading to Gastric Ulceration After Hepatic Artery Infusion

Abstract

Commonly experienced symptoms post transarterial chemoembolization include abdominal pain, nausea, fever and ileus. There are case reports of non-target embolization. The goal is to describe a unique case of suspected chemotherapy induced gastric ulcers after hepatic artery infusion. A 72-year-old man with hepatitis C-related cirrhosis presented to our tertiary care center for transarterial chemoembolization (TACE) of a known hepatocellular carcinoma (HCC). The patient had initially been treated with the first dose of loco-regional therapy using 50 milligrams (mg) of doxorubicin in DC BeadTM. There were no noted complications from this procedure. Six months later, he was brought to IR for consideration for repeat TACE as a treatment as well as a possible bridge to surgical intervention. During transarterial chemoembolization, a 5-French catheter was advanced to identify the ostium of the celiac artery. An angiogram was performed, demonstrating adequate catheter position. A microcatheter was then advanced into the left hepatic artery. The catheter could not be advanced distally due to the presence of spasm despite giving nitroglycerin. An additional angiogram was performed, which demonstrated the known HCC in the left lobe. Chemoembolization was performed with approximately 70 mg of doxorubicin in DC BeadTM. There was no evidence of nontarget embolization of any adjacent organs including the gastric cardia. The patient experienced persistent nausea and vomiting that prompted admission for two days post-procedure. It was treated conservatively with pharmacologic 5-HT3 receptor antagonists as needed. The symptoms were attributed to the doxorubicin and resolved at time of discharge. 72 hours later, the patient presented to hospital with acute onset hematemesis and suspected upper gastrointestinal bleeding. He was stabilized with blood products and vasopressor therapy. Urgent gastroscopy revealed multiple irregular ulcers. There was a Forrest class 1b ulcer on the lesser curvature and a Forrest class 2c ulcer noted on the incisura. Treatment was applied with both epinephrine and clips with good hemostatic response. Biopsies were taken from the edge of the ulcer. Biopsy samples were reviewed to rule out possible malignancy. The histologic findings included basophilic microspheres on the background of purulent exudate and necrotic debris. The findings were most consistent with gastric ulcers secondary to drug eluting beads. Repeat gastroscopy showed that the previous ulcerations had coalesced to encompass a large portion of the lesser curvature of the stomach. There was no evidence of active bleeding. Subsequently, the patient was treated conservatively and observed until discharge from hospital.Figure 1Figure 2