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         CASE SNIPPET Year : 2023  |  Volume : 69  |  Issue : 4  |  Page : 237-238

Unusual upper gastrointestinal bleeding following radiofrequency ablation and transarterial chemoembolization for hepatocellular carcinoma

CW Chang, HW Wang, WH Huang, PH Chuang
Department of Internal Medicine, Center for Digestive Medicine, China Medical University Hospital, Taichung, Taiwan

Date of Submission06-Aug-2021Date of Decision15-Nov-2021Date of Acceptance09-Dec-2021Date of Web Publication23-Feb-2023

Correspondence Address:
Dr. H W Wang
Department of Internal Medicine, Center for Digestive Medicine, China Medical University Hospital, Taichung
Taiwan

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jpgm.jpgm_764_21

How to cite this article:
Chang C W, Wang H W, Huang W H, Chuang P H. Unusual upper gastrointestinal bleeding following radiofrequency ablation and transarterial chemoembolization for hepatocellular carcinoma. J Postgrad Med 2023;69:237-8
How to cite this URL:
Chang C W, Wang H W, Huang W H, Chuang P H. Unusual upper gastrointestinal bleeding following radiofrequency ablation and transarterial chemoembolization for hepatocellular carcinoma. J Postgrad Med [serial online] 2023 [cited 2023 Oct 19];69:237-8. Available from: https://www.jpgmonline.com/text.asp?2023/69/4/237/370403

A 59-year-old woman with a history of hepatitis C-related liver cirrhosis and hepatocellular carcinoma (HCC) with left lobe tumor recurrence presented with progressive anemia. She had received radiofrequency ablation (RFA) 1 month ago and developed mild anemia (hemoglobin [Hb]: 11 g/dL). The follow-up abdominal computed tomography (CT) revealed recurrent HCC (segment 3) following RFA with a left lobe viable tumor (measuring 2.3 cm × 2 cm) in segment 3 of the liver with an exophytic pattern near the stomach [Figure 1]a and [Figure 1]b. Subsequently, transarterial chemoembolization (TACE) was performed. However, despite the extent to which the patient's Hb decreased in a month (i.e., from 11.5 to 6.5 g/dL), no obvious tarry or bloody stool was observed. Esophagogastroduodenoscopy (EGD) was arranged, which revealed a bulging mass measuring 4–5 cm in size with a 2–3-cm overlying ulceration on the anterior wall from the high body to cardia [Figure 2]a. Furthermore, no obvious active bleeding was noted during EGD. We assumed that her anemia was related to chronic blood loss. The endoscopic ultrasound (EUS) confirmed that this ulcerative mass lesion was compatible with left lobe HCC following RFA and TACE [Fig. 1b]. Further biopsy was not performed during EUS because the location of the bulging mass lesion corresponded to the location of the left lobe HCC detected in a previous CT study. Because of the absence of active bleeding, we initially implemented conservative treatment for the patient. After the patient underwent conservative treatment with a proton pump inhibitor (PPI) and adequate blood transfusion (4 units of packed red blood cells [pRBC]), her follow-up hemoglobin (Hb) was 9.3 g/dL. She was then discharged in a stable condition. A follow-up EGD conducted 1 month later revealed healing ulcers on the previous gastric bulging mass lesion [Figure 2]b; at this point, her follow-up Hb was 12.2 g/dL. Her anemia and ulcer improved after she received conservative treatment with PPI. We assumed that her ulcer was related to tumor necrosis. Because a biopsy was not performed during the EGD, tumor invasion could not be ruled out.

Figure 1: (a) abdominal computed tomography scan revealing a viable tumor measuring 2.3 cm × 2 cm in segment 3 of the left lobe of the liver with exophytic pattern near the stomach (arrow); thrombus in left portal vein and presence of hepatocellular carcinoma in segments 7 and 8 following radiofrequency ablation; (b) endoscopic ultrasound revealing an extraluminal polypoid lesion (43 mm × 34 mm); hyperechoic echogenicity and indistinct margins were considered because of external compression from the liver tumor

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Figure 2: Esophagogastroduodenoscopy showing (a) gastric varices at fundus without active bleeding / recent signs of hemorrhage; a gastric bulging mass (4–5 cm) with overlying ulceration (2–3 cm) from high body to cardia of the stomach; (b) endoscopic evaluation conducted 1 month after TACE revealing healing ulcers and regression of the gastric bulging mass

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Transarterial chemoembolization is a commonly used treatment modality for HCC. It is performed by super-selectively injecting chemotherapy agent or drug-eluting beads into a target tumor and embolizing its feeding vessels, thereby, inducing ischemia and necrosis in the target tumor. Treated HCC-related gastric ulceration is a rare condition of nonvariceal upper gastrointestinal (GI) bleeding. Reports have revealed the association of the development of hepatogastric fistula with locoregional treatment (e.g., TACE, RFA, and radiotherapy).[1],[2],[3] A possible pathophysiologic mechanism for HCC-related gastric ulceration is post-treatment-related tumor necrosis and inflammatory reaction, which can directly cause tumor involvement into an adjacent organ or indirectly lead to gastric ulceration. Sayana et al.[4] reported that an exophytic tumor growth pattern can easily result in pressure necrosis and tumor invasion to the proximal organ. In addition to the tumor growth pattern, other risk factors for direct invasion include tumor location, tumor size, and recent locoregional interventions.[2] The current patient's target tumor had several predisposing risk factors, including the location of the left lobe, an exophytic growth pattern, and the recent administration of RFA and TACE. We assumed that her HCC progression was related to the target tumor's ischemic reaction and inflammatory process, which could have led to the development of the observed HCC-related gastric ulceration. The management of treated HCC-related gastric ulceration includes PPI treatment and endoscopic hemostasis. Transarterial embolization or even surgical intervention may be considered if severe GI bleeding occurs. Clinicians should be aware of an unexpected ulcerative pattern at an unusual location in the stomach and should investigate it as early as possible after the administration of locoregional treatment for HCC.

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

 :: References 
1.Wang CY, Leung SW, Wang JH, Yu PC, Wang CC. Delayed spontaneous hepatogastric fistula formation following transcatheter arterial embolisation and radiotherapy for hepatocellular carcinoma. Br J Radiol 2009;82:e105-7.  
    2.Park H, Kim SU, Choi J, Park JY, Ahn SH, Han KH, et al. Hepatogastric fistula caused by direct invasion of hepatocellular carcinoma after transarterial chemoembolization and radiotherapy. Korean J Hepatol 2010;16:401-4.  
    3.Brown C, Chen C, Cha C. Gastrohepatic fistula as a complication of laparoscopic radiofrequency liver ablation in a patient with intrahepatic cholangiocarcinoma. J Clin Gastroenterol 2014;48:563-4.  
    4.Sayana H, Yousef O, Clarkston WK. Massive upper gastrointestinal hemorrhage due to invasive hepatocellular carcinoma and hepato-gastric fistula. World J Gastroenterol 2013;19:7472-5.  
    
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