Aminocaproic acid used to control upper gastrointestinal bleeding in radiation gastritis

Clinical course and treatment of radiation-induced hemorrhagic gastritis: a case series study

Radiation-induced hemorrhagic gastritis is a relatively uncommon complication of irradiation that can be severe. However, appropriate treatment guidelines have not yet been established because of the small number of known cases. At our hospital, we encountered nine cases of radiation-induced hemorrhagic gastritis between July 2005 and July 2018. All patients initially underwent argon plasma coagulation (APC) for hemostasis. The treatment was highly effective, and hemostasis was successfully achieved in eight of the cases. Hemostasis could not be achieved in one case treated with APC; therefore, surgical resection was required. This patient had risk factors, such as liver cirrhosis and a history of abdominal surgery. Our case series suggests that APC is an effective hemostatic method that should be considered as the initial treatment option for radiation-induced hemorrhagic gastritis; however, surgical resection may be considered when the patient is at high risk for rebleeding.

Radiation in Gastroenterology

The benefit of radiation is immense in the field of gastroenterology. Radiation is used daily in different gastrointestinal imaging and diagnostic and therapeutic interventional procedures. Radiotherapy is one of the primary modalities of treatment of gastrointestinal malignancies. There are various modalities of radiotherapy. Radiotherapy can injure malignant cells by directly damaging DNA, RNA, proteins, and lipids and indirectly by forming free radicals. External beam radiation, internal beam radiation and radio-isotope therapy are the major ways of delivering radiation to the malignant tissue. Radiation can also cause inflammation, fibrosis, organ dysfunction, and malignancy. Patients with repeated exposure to radiation for diagnostic imaging and therapeutic procedures are at slightly increased risk of malignancy. Gastrointestinal endoscopists performing fluoroscopy-guided procedures are also at increased risk of malignancy and cataract formation. The radiological protection society recommends certain preventive and protective measures to avoid side effects of radiation. Gastrointestinal complications related to radiation therapy for oncologic processes, and exposure risks for patients and health care providers involved in diagnostic or therapeutic imaging will be discussed in this review.

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

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.

Gastrointestinal chronic graft-versus-host disease: management options

Chronic graft-versus-host disease (GVHD) is a common and debilitating condition afflicting a number of allogeneic stem cell recipients more than 100 days after their transplant. Limited options are available for the acute management of patients with severe gastrointestinal (GI) symptoms including gastric bleeding. Along with increased immunosuppression and aggressive supportive care, we report here the use of aminocaproic acid in the management of patients with GI bleeding resulting from severe GVHD. The use of aminocaproic acid enabled us to reduce the frequency and number of blood product transfusions required to manage our patient. Anti-fibrinolytic agents may therefore serve as useful adjunctive but underutilized therapy in the management of patients with severe GI chronic GVHD. J Oncol Pharm Practice (2007) 13: 49–51.

Subtotal gastrectomy for diffused hemorrhagic gastritis induced by radiation, following liver resection for hilar cholangiocarcinoma. A case report

INTRODUCTION

A rare case of hemorrhagic gastritis induced by radiation is presented, which was resistant to conservative treatment and required subtotal gastrectomy.

PRESENTATION OF CASE

A 56-year-old male was initially undergone right hepatectomy, resection of the extrahepatic biliary tree, hilar lymph node dissection and hepatico-jejunostomy due to advanced hilar cholangiocarcinoma. Because of the extent of the disease, chemo-radiotherapy was administered. The patient received a total radiotherapy dose of 57.6Gy in 32 sessions. Unfortunately, diffused hemorrhagic gastritis induced by radiation was developed, which was resistant to conservative treatment (endoscopic hemostasis, transfusion). A subtotal gastrectomy was performed. The patient is in good condition 45 months after the liver resection, but with local recurrence.

CONCLUSION

In resistant situations to conservative treatment and recurred bleeding of diffused hemorrhagic gastritis induced by radiation, surgical management may have a role.

A case of post-radiotherapy gastritis: radiation does not explain everything

Hemorrhagic gastritis is a possible late toxicity outcome after radical radiotherapy but it is nowadays a very rare condition and most likely depends on other clinical factors. We report the case of a 77-year-old woman with a symptomatic solitary extramedullary intra-abdominal plasmacytoma and multiple gastric comorbidities, treated with external beam radiotherapy. Despite the good response to radiotherapy, the patient experienced multiple gastric bleeding a few months later, with the need of multiple treatments for its control. In this paper we will discuss in detail all aspects related to the different causes of hemorrhagic gastritis.

Efficacy of argon plasma coagulation in the treatment of radiation-induced hemorrhagic gastroduodenal vascular ectasia

OBJECTIVE

Radiation-induced hemorrhagic gastroduodenal vascular ectasia (GDVE) is rare but difficult to manage. Argon plasma coagulation (APC) has not yet been evaluated in the treatment of radiation-induced hemorrhagic GDVE. The efficacy of APC in patients with radiation-induced hemorrhagic GDVE has been investigated in this article.

MATERIAL AND METHODS

Eighteen patients with upper gastrointestinal (GI) bleeding caused by radiation-induced GDVE, including 13 with hepatocellular carcinoma, 3 with pancreatic cancer, and 2 with cholangiocarcinoma, were treated with APC. The efficacy of APC was retrospectively evaluated, based on cessation of macroscopic GI bleeding, resolution or stabilization of anemia and transfusion dependence, endoscopic ablation of almost all vascular lesions, complications, and recurrence.

RESULTS

Mean patient age was 59 years (range 42-80 years). The median time from radiation to GDVE diagnosis was 4.6 months (range 3.3-21.5 months). The median number of APC sessions per patient was 2.4 (range 1-4). All 18 patients showed an endoscopic response to APC treatment, with sustained increases in mean hemoglobin level, from 6.6 g/dL (range 2.9-9.5 g/dL) to 9.7 g/dL (range 7.1-12.7 g/dL) (p < 0.001), and decreased dependence on transfusion, from 9.1 (range 0-30) to 4.1 (range 0-15) units of packed red blood cells per patient (p = 0.038) after last endoscopic eradication by APC treatment. There were no major procedure-related adverse events or deaths. At a median follow up of 4.7 months (range 0.6-24.5 months), none of the patients experienced recurrence of GDVE.

CONCLUSIONS

APC showed short-term effectiveness and safety in the treatment of radiation-induced hemorrhagic GDVE.

Surgical management of complications of multimodal therapy

Multimodality therapies that include surgery, chemotherapy, radiotherapy, and various newer forms of targeted therapies have been commonly applied in childhood cancers. Such modalities are associated with complications that may adversely affect the outcome of cancer treatment. Acute complications that require surgical management form the focus of our discussion. These patients are often compromised by immunosuppression, thrombocytopenia, and malnutrition. The complications discussed include typhlitis, invasive aspergillosis (IA), pancreatitis, hemorrhagic cystitis, gastrointestinal hemorrhage, necrotizing skin and soft-tissue infections, and perianal infection. Familiarity with the spectrum of complications and their appropriate management approaches will minimize the patients' morbidity.

Hemorrhagic radiation gastritis successfully treated with repeated intra-arterial steroid infusions

Intra-arterial steroid infusion therapy has previously been shown to be effective for inflammatory bowel disease; however, few cases in which it has been used for the treatment of hemorrhagic radiation gastritis have been reported. We report the case of a 70-year-old Japanese man with hemorrhagic radiation gastritis induced by radiation therapy for para-aortic lymph node metastases of hepatocellular carcinoma. Two months after completing radiation therapy, acute persistent bleeding occurred in the gastric irradiation area. Although argon plasma coagulation was performed five times over a month, the bleeding continued and the patient showed persistent anemia that required 50 units of blood transfusion. Finally, the patient was given intra-arterial steroid infusions through the right gastric artery and the right gastroepiploic artery. After three intra-arterial steroid infusions, the melena stopped, and the anemia no longer progressed. Hemorrhagic radiation gastritis was successfully treated with repeated intra-arterial steroid infusions through the regional vessels to the gastric mucosa. Repeated intra-arterial steroid infusions could be a clinically useful option for the treatment of intractable bleeding from radiation gastritis.

Argon plasma coagulation therapy for a hemorrhagic radiation-induced gastritis in patient with pancreatic cancer

Radiation-induced gastritis is a serious complication of radiation therapy for pancreatic cancer which is difficult to manage. A 79-year-old man had been diagnosed as having inoperable pancreatic cancer (stage IVa). We encountered this patient with hemorrhagic gastritis induced by external radiotherapy for pancreatic cancer that was well-treated using argon plasma coagulation (APC). After endoscopic treatment using APC, anemia associated with hemorrhagic radiation gastritis improved and required no further blood transfusion.

Hyperbaric oxygen treatment of hemorrhagic radiation-induced gastritis after esophagectomy

My colleagues and I present 2 cases of hemorrhagic postesophagectomy gastritis after chemoradiotherapy for esophageal cancer. On the basis of the location of the gastritis (lesser curve and midstomach) and the classic radiation injury appearance, radiation damage was believed to be the cause. In both patients, hyperbaric oxygen therapy rapidly arrested bleeding. This is the first description in which hyperbaric oxygen therapy was used to treat hemorrhagic postesophagectomy gastritis.

Surgical treatment of recalcitrant radiation-induced gastric erosions

BACKGROUND

Uncontrolled bleeding as a result of radiation gastritis in patients who have pharyngo-laryngo-esophagectomy and gastric pull-up is seldom reported. Surgical resection in the management of this condition has rarely been described.

METHOD

A 66-year-old man with hypopharyngeal cancer was treated by pharyngo-laryngo-esophagectomy and gastric transposition. He received postoperative radiotherapy and had recurrent hemorrhagic gastritis, necessitating surgical resection. The manubrium was resected to access the mediastinal part of the gastric conduit. The diseased part of the gastric conduit was removed and a free jejunal graft was interposed to replace the resected stomach.

RESULTS

Manubrial resection offered adequate access to the stomach transposed in the mediastinum, and the life-threatening bleeding gastritis was successfully controlled by surgical resection.

CONCLUSION

Surgical resection of the radiation-damaged transposed stomach through a manubrial resection approach can safely be performed. Free jejunal graft is the choice of reconstruction of the circumferential defect.