Diagnosis, pathophysiology, and treatment of SIRT-induced gastroduodenal ulcers: A systematic literature review

Abstract

Background: Selective Internal Radiation Therapy (SIRT) is a therapeutic modality in patients with hepatocellular carcinoma or liver metastases. Complications due to SIRT-induced gastric ulcers are seen in less than 5% of patients but there is no consensus for management of this rare side effect. We conducted a systematic review to analyze the efficacy of medical treatment of SIRT-induced ulcers. Methods: This systematic review was conducted in accordance with the PRISMA guidelines. We developed the research question following the population, intervention, comparison, outcome, and study design (PICOS) format. We identified studies and cases reporting patients with gastric and/or duodenal (=population) ulcers treated with medical therapy with proton pump inhibitor (PPI), antacid, or sucralfate, alone or in combination (=intervention). We did not require that studies include a control group. We included studies reporting the evaluation of the medical and/or surgical treatment (=outcomes). Results: Out of 219 articles, 29 articles were included, resulting in analysis of data for a total of 51 patients who had a SIRT-induced gastric and/or duodenal ulcer treated with medication, surgery, or both. Twenty-eight patients (55%) were reported to have SIRT-induced ulcers that improved after initiation of PPI, antacid, or sucralfate treatment (alone or in combination). Twenty-three patients (45%) were reported to be refractory to medical treatment and surgery was performed in 7 out of 23 patients (30%). Conclusions: About 45% of SIRT-induced gastroduodenal ulcers are refractory to medical treatment with PPI, antacid, or sucralfate, alone or in combination. Surgery is an effective treatment in patients who are refractory to medical treatment and who have intense symptoms.

Laparoscopic Gastrojejunostomy for the Treatment of SIRT-Induced Duodenal Ulcer Complicated by Gastric Outlet Obstruction

“…These ulcers have proven to be difficult to treat and may be associated with severe abdominal pain, upper gastrointestinal, bleeding, bowel perforation, and obstruction. 1 In our case, the duodenal ulcer was diagnosed 6 months after the procedure, localized in the bulb, rather than antrum and pylorus (commonly reported localizations). 2 The anatomic variant of the left hepatic artery arising from left gastric artery (less commonly reported than the aberrant right hepatic artery) 2 may put this patient at risk for retrograde flow of the microspheres.…”

“…These ulcers have proven to be difficult to treat and may be associated with severe abdominal pain, upper gastrointestinal, bleeding, bowel perforation, and obstruction. 1…”

“…4 The pathophysiology of the gastrointestinal ulcers results mainly from direct radiation mucosal injury in addition to ischemic injury due to mechanical arteriolar obstruction. 1,4 Incidence of ulcerations decreased from 25% to less than 5% after strict adherence to contemporary protocols consisting of angiographic studies to assess the hepatic vasculature anatomy prior to procedure and to rule out any shunt. 2 Median ulceration rate reported in previous studies was 8%, ranging from 0 to 20%, with 6% requiring surgical management mainly gastrectomy.…”

“…Selective internal radiation therapy (SIRT) is an emerging therapeutic modality in patients with unresectable hepatocellular carcinoma or liver metastases. 1,2 The procedure's rationale is that these tumors are vascularized by arterial blood flow, in contrast to normal hepatic parenchyma supplied by portal blood flow. 1,3 Injecting β-emitting yttrium-90 ( 90 Y) microspheres into the hepatic arteries leads to necrosis of the lesion.…”

“…1,2 The procedure's rationale is that these tumors are vascularized by arterial blood flow, in contrast to normal hepatic parenchyma supplied by portal blood flow. 1,3 Injecting β-emitting yttrium-90 ( 90 Y) microspheres into the hepatic arteries leads to necrosis of the lesion. 4 However, complications have been described when radiation injury occurs in extrahepatic organs due to embolization of radioactive beads in other arteries.…”