Severe Gastric Ulcers due to Radiation with Yttrium-90 Microspheres

CASE REPORT

Final Diagnosis

Gastric ulceration due to Yttrium-90 microsphere embolization.

Patient Demographics

1. A 75-year-old female.
2. History of stage IIIC hepatocellular carcinoma.
3. History of Yttrium-90 selective tumor embolizatio for two years.

Clinical History

1. The patient also received monoclonal antibody therapy for hepatocellular carcinoma.
2. She underwent Yttrium-90 transarterial radioembolization for hepatocellular carcinoma.
3. She presented with severe abdominal pain, nausea, vomiting, and weight loss several weeks after her last embolization, prompting esophagogastroduodenoscopy.

Endoscopic Findings

1. Esophagogastroduodenoscopy revealed multiple, very large gastric ulcers located in the fundus and proximal body of the stomach.
2. The ulcers were covered by fibrin.
3. Two areas of visible vessels were noted within the ulcers.
4. No active bleeding was observed during the procedure.

Endoscopic Technique

1. A standard upper endoscope was used to visualize the stomach.
2. The ulcers were documented and characterized.
3. Biopsies were obtained.

Discussion

1. Yttrium-90 (Y-90) transarterial radioembolization is an interventional radiology technique used to treat hepatocellular carcinoma and metastatic colon cancer (1-3).
2. This therapy is generally considered safe and effective, with increasing utilization over time.
3. Complications such as duodenal and gastric ulcers have been reported, with an incidence ranging from 2% to 4% (4).
4. These ulcers result from inadvertent delivery of Y-90 microspheres to the microvasculature of the stomach or duodenum, leading to direct radiation toxicity (4).
5. Symptoms, including abdominal pain, weight loss, vomiting, anorexia, and bleeding, typically arise hours to months after therapy (1-4).
6. Severe cases of sepsis due to perforation have been reported (3).
7. Diagnosis is made endoscopically and histologically.
8. These radiation-induced gastric ulcers are often recalcitrant to standard proton pump inhibitor therapy due to a distinct pathophysiology, as the damage is radiogenic and extends transmurally across the entire thickness of the gastrointestinal tract wall.

Key Learning Points

1. Yttrium-90 radioembolization can cause severe gastric and duodenal ulcers due to inadvertent microsphere delivery.
2. Endoscopic diagnosis is crucial for characterizing these radiation-induced ulcers.
3. Radiation-induced gastrointestinal ulcers typically present with abdominal pain, nausea, vomiting, and weight loss, and may not respond to conventional acid suppression therapy.
4. These ulcers can have significant morbidity, including perforation and sepsis.
5. Awareness of this complication is essential for appropriate patient management following Y-90 radioembolization.

References

1. Riaz A, Lewandowski RJ, Kulik LM, et al. Practical management of complications following yttrium-90 radioembolization. Semin Intervent Radiol. 2011;28(4):450-459.
2. Hasteh F, Dasyam AK, Kothary N, et al. Gastric and Duodenal Ulceration after Yttrium-90 Radioembolization: Etiology, Clinical Presentation, and Management. J Vasc Interv Radiol. 2017;28(10):1442-1448.
3. Kallini JR, Gabr A, Wade T, et al. Complications of Yttrium-90 Radioembolization. Tech Vasc Interv Radiol. 2017;20(2):121-127.
4. Mushtaq M et al. Gastric ulcers located with Ytrrium-90 microsphere selective internal radiation therapy. Cureus 2024;16:e58702.