Upper Gastrointestinal Bleeding From Ischemic Gastropathy After TACE Therapy

Abstract

Transarterial chemoembolization (TACE) therapy is used in the treatment of unresectable hepatocellular carcinomas. TACE involves the injection of a chemotherapeutic agent into the hepatic artery which results in decreased blood supply to the liver tumor and resultant tumor cell death. Rare complications of TACE therapy including hepatic artery occlusion, tumor rupture, liver abscess, and ischemic injury related to non-target embolization. GI bleeding due to ischemic gastropathy, however, is rare due to the extensive collateral blood supply of the stomach. A 63 year-old male with hepatitis C and alcoholic cirrhosis complicated by esophageal varices, hepatic encephalopathy, and hepatocellular carcinoma was admitted for his fourth TACE therapy. The patient developed abdominal discomfort and hematemesis the following day. Patient was tachycardic during episodes of hematemesis but was otherwise stable with no transfusion requirements. Upper endoscopy later that day revealed non-bleeding small esophageal varices and extensive areas of blackened mucosa from the proximal stomach to duodenum with nodularity, tissue friability, erosions, and adherent clots. Mucosal changes were most pronounced in the mid and distal stomach. Diffuse erosions were also noted in the proximal duodenum, but there was a discrete transition point to normal mucosa between the 2nd and 3rd portions of the duodenum. Hematemesis was thought to be related to severe inflammation and friability in stomach and proximal duodenum, and patient had clinical improvement with supportive care. Gastrc biopsies demonstrated fibrinoid change of lamina propria, glandular atrophy, and purulent exudate consistent with ischemic gastritis. Duodenal biopsies also demonstrated focal fibrinoid change of lamina propria and glandular atrophy also consistent with ischemia. This case was discussed with interventional radiology, and previously treated branches of the right and left hepatic artery had appeared atretic. Visualization of the hepatic lesion was therefore limited, and the decision was made to treat non-selectively via the left hepatic and middle hepatic artery which likely resulted in embolization of vasculature supplying the stomach and proximal duodenum. Most patients have resolution of symptoms with supportive care. PPI therapy has also been suggested to promote mucosal healing. Patients would benefit from monitoring after TACE therapy especially if less-selective embolization is performed.2338_A Figure 1 No Caption available.2338_B Figure 2 No Caption available.2338_C Figure 3 No Caption available.