Upper GI Bleeding Secondary to Radiation Gastritis in a Patient with Preexisting Portal Hypertensive Gastropathy

Abstract

We commonly see patients presenting with either portal hypertensive gastropathy (PHG) or radiation gastritis. Radiation-induced hemorrhagic gastritis is an unusual lethal complication postradiation. Patients with preexisting PHG have very friable mucosa that can easily bleed after radiation for cancer treatment. There is an increased risk of bleeding with both entities present together. Our aim is to focus on treatment and possible prevention of gastrointestinal bleeding in patients with preexisting PHG undergoing radiation therapy for newly diagnosed cancer. Several therapies like prednisolone, argon plasma coagulation, laser coagulation have been proposed. There are no set guidelines for treatment. In these patients, if radiation therapy is indicated either for hepatic or gastrointestinal malignancy, it is suggested to premedicate with proton pump inhibitors or sucralfate. We describe a case of 73-year-old female who presented with upper gastrointestinal bleeding. She had liver cirrhosis secondary to nonalcoholic fatty liver disease and diagnosed with pancreatic cancer, for which she received chemoradiation. She was found to have both radiation gastritis and PHG with diffuse erythematous, edematous, congested mucosa with diffuse oozing blood in the antrum making it very challenging to treat.

Recurrent Upper Gastrointestinal Bleeding due to Radiation-Induced Hemorrhagic Gastroduodenal Ectasia: A Review of Current Treatment Options for Radiation-Induced Gastric Injury

“…The underlying pathophysiology is characterized initially by acute inflammation of the gastric mucosa, and as the injury progresses, vasculopathy may evolve to progressive obliterative endarteritis and endothelial proliferation that leads to mucosal ischemia, ulceration, and telangiectasia [ 9 ]. The severity of damage is directly related to the high total dose and high daily fraction of radiation used [ 10 ]. The incidence of gastric ulcers due to radiation therapy is between 25 and 30% as the dose exceeds 45 Gy with risk of perforation when dose exceeds 60 Gy [ 11 ].…”

Radiation in Gastroenterology

“…Currently, there is no standard guideline for treating RIG. The different modalities of treatment include conservative treatment (PPI, sucralfate, anti-emetics) for non-hemorrhagic RIG, endoscopic treatment (argon plasma coagulation, endoscopic band ligation, radiofrequency ablation, cryotherapy), oral prednisone, epsilon aminocaproic acid, and surgical resection for hemorrhagic RIG, and hyperbaric oxygen therapy for non-healing gastric ulcers [ 46 - 48 ].…”