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Argon Plasma Coagulation Therapy for a Hemorrhagic Radiation-Induced Gastritis in Patient with Pancreatic Cancer

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Argon Plasma Coagulation Therapy for a Hemorrhagic Radiation-Induced Gastritis in Patient with Pancreatic Cancer □ CASE REPORT □ Argon Plasma Coagulation Therapy for a Hemorrhagic Radiation-induced Gastritis In patient with Pancreatic Cancer Kazutaka Shukuwa, Keiichiro Kume, Masahiro Yamasaki, Ichiro Yoshikawa and Makoto Otsuki Abstract 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. Key words: argon plasma coagulation (APC), hemorrhagic radiation-induced gastritis (DOI: 10.2169/internalmedicine.46.0076) had required transfusion with 6 units red blood cells in one Introduction month. The endoscopic examination showed edematous mu- cosa with multiple telangiectasias and oozing in the whole Radiation-induced gastritis is a serious complication of ra- antral distribution which were thought to be induced by ra- diation therapy for pancreatic cancer and difficult to man- diation (Fig. 1). He was diagnosed as radiation-induced gas- age. We encountered a patient with hemorrhagic gastritis in- tritis. He was treated by endoscopic APC (ERBE; APC300) duced by external radiotherapy for pancreatic cancer that and received 20 mg tablets of omeprazole (Fig. 2). The ar- was well-treated using argon plasma coagulation (APC). Af- gon gas flow was set at 2 l/min with a coagulation power ter endoscopic treatment using APC, anemia associated with setting of 60W. One month after the first APC, additional hemorrhagic radiation gastritis improved and required no APC was perfomed for the remaining telangiectasia. His further blood transfusion. condition improved dramatically and his tarry stool stopped after the second treatment by APC. His hemoglobin has re- Case Report mained stable for 2 months without blood transfusions until he died due to pancreatic cancer in February 2005. A 79-year-old man was referred for evaluation and treat- ment of pancreatic tumor in June 2004. Computed tomogra- Discussion phy (CT) showed diffuse tumor of the pancreas with inva- sion of the celiac artery, and ultrasonography (US) showed APC is a noncontact method for delivering high- hypoechoic mass on pancreatic body and tail. He was diag- frequency alternating current by means of ionized, electri- nosed as having inoperable pancreatic cancer (stage IVa). cally conductive argon gas. The no touch application of the The patient was treated with chemotherapy (gemcitabine 50 coagulation energy via ionized argon prevents the probe mg/m2, biweekly) and external beam radiotherapy (total 61.2 from sticking to the tissue. The limited depth of coagulation Gy) to the whole pancreas from June 18 to August 31. Two (2-3 mm) explains the low risk of perforation (1). APC has months after radiotherapy, the patient had tarry stool and been perfomed with a flexible endoscope since 1991 (2). anemic aggravation. Hemoglobin levels were 6.4 bg/dl. He This technique is considered useful for the management of Department of Gastroenterology and Metabolism, University of Occupational and Environmental Health, Japan, Shool of Medicine, Kitakyushu Received for publication February 2, 2007; Accepted for publication March 28, 2007 Correspondence to Dr. Makoto Otsuki, [email protected] 975 DOI: 10.2169/internalmedicine.46.0076 Figure 1. Endoscopic appearance showing multiple Figure 2. Endoscopic appearance of antral mucosa after ar teleangiectasias at diffuse antral mucosa after radiation gon plasma coagulation therapy; multiple teleangiectasias therapy. were replaced by superficial ulcers with blood clot. vascular lesions such as gastric antral vascular ectasia ing and is relatively resistant to radiation. But radiologic du- (GAVE), malignant tumors, hemostasis of bleeding peptic rability dosage of the stomach and intestine is regarded as ulcers, esophageal varices, and Barret’s esophagus (2). 45 Gy, and that of rectum is regarded as 55 Gy. The time Many investigators have comfirmed the value of APC in lag of two months between radiation and gastritis was treating many cases of radiation-induced proctsigmoiditis1 thought to be because the radiolesion was in an early stage. (1, 3-7). Morrow et al (8) reported a patient with radiation- The incidence of radiation gastritis is very low because the induced carditis who was succescfully treated with APC, stomach is rarely within the treated field, but it is important and Wada et al (9), Coabinais et al (10) reported a patient to be aware that the stomach is by no means more radiore- with radiation-induce gastritis. Radiation-induced gastritis is sistant than other organs. Acute vasculopathy may progress a diffuse process with multiple bleeding sites leading to to prolonged and progressive obliterative endarteritis, vascu- blood loss requiring multiple blood transfusion (11). APC litis, and endothelial proliferation, leading to mucosal ische- seems to be suitable for thermal coagulation of hemorrhagic mia, ulceration, and mucosal telangiectasias and, ultimately, radiation-induced vascular lesions. The present patient had fibrosis (11). The development of new indications for upper ongoing gastric bleeding with symptomatic anemia requiring gastrointestinal radiotherapy in the treatment of pancreatic transfusions of multiple packed red blood cells because of cancer, is likely to lead to an increased incidence of upper the inability to maintain hemoglobin levels 9 g/dl. But after digestive bleeding caused by radiation-induced gastroduode- two times of APC, the bleeding never recurred until he died nal vasculopathy. Because our observation is limited to one with pancreatic cancer. patient, further studies are necessary to confirm the effec- The stomach has a thick muscular coat and mucosal lin- tiveness of APC for radiation-induced gastritis. References 1. Kassis M, Oberti E, Burtin P, Boyer J. Argon plasma coagulation Dis Colon Rectum 44: 1766-1771, 2001. for the treatment of hemorrhagic radiation proctitis. Endoscopy 6. Venkatesh KS, Ramanujam P. Endoscopic therapy for radiation 32: 673-676, 2000. proctitis-induced hemorrhage in patients with prostatic carcinoma 2. Tanabe S, Kitamura T, Saigenji K. The present state and future using argon plasma coagulator application. Surg Endosc 16: 707- possibility of argon plasma coagulation therapy. Gastroenterol En- 710, 2002. dosc 46: 2391-2398, 2004. 7. Tam W, Moore J, Schoeman M. Treatment of radiation proctitis 3. Silva RA, Correia AJ, Dias LM, Viana HL, Viana RL. Argon with argon plasma coagulation. Endoscop 32: 667-672, 2000. plasma coagulation therapy for hemorrhagic radiation proctosig- 8. Morrow JB, Dumot JA, Vargo JJ. Radiation-induced hemorrhagic moiditis. Gastrointest Endosc 50: 221-224, 1999. carditis treated with argon plasma coagulator. Gastrointest Endosc 4. Tjandra JJ, Sengupta S. Argon plasma coagulation is an effective 51: 498-499, 2000. treatment for refractory hemorrhagic radiation proctitis. Dis Colon 9. Wada S, Tamada K, Tomiyama T, Yamamoto H, Nakazawa K, Rectum 44: 1759-1764, 2001. Sugano K. Endoscopic hemostasis for radiation-induced gastritis 5. Taieb S, Rolachon A, Cenni JC, et al. Effective use of argon using argon plasma coagulation. J Gastroenterol Hepator 18: plasma coagulation in the treatment of severe radiation proctitis. 1215-1218, 2003. 976 DOI: 10.2169/internalmedicine.46.0076 10. Corbinais S, Garin L, Pagenault M, Bretagne JF. Successful treat- 11. Grover N, Johnson A. Aminocaproic acid used to control upper ment by argon plasma coagulation of bleeding radiation-induced gastrointestinal bleeding in radiation gastritis. Dig Dis Sci 42: gastroduodenal vasculopathy. Endoscopy 34: 593, 2002. 982-983, 1997. Ⓒ 2007 The Japanese Society of Internal Medicine http://www.naika.or.jp/imindex.html 977.
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