Lorraine Tulpin

Treating upper digestive bleeding may cause multiple infectious complications in a cancer patient

A 52-year-old patient was diagnosed on October 2018 with a pancreatic adenocarcinoma metastatic to the liver. On initial assessment, the tumor was found laminating the gastro-duodenal artery, invading the duodenal wall and obstructing the common biliary tract with dilation of the intra- and extrahepatic bile ducts without any signs of cholangitis. A self-expanding metallic stent was successfully inserted in the distal common bile duct. A 1^st cycle of combined gemcitabine/nab-paclitaxel was administered on December 2018. Three weeks later, the patient was admitted with hematemesis and hypotension. On gastroscopy and abdominal CT Scan, an active bleeding of the duodenal bulb and a covered perforation of the duodenum caused by the metallic biliary endoprosthesis were found. Immediate hemorrhagic recurrence occured after an initial attempt of Hemospray® treatment, leading to a hemorrhagic shock. An angio CT scan demonstrated a rupture of a gastro-duodenal artery stump, treated successfully by embolization of the common hepatic artery, the proper hepatic artery and the gastroduodenal artery during active hemodynamic resuscitation using liquid embolic agent (lipiodol + N-Butylcyanoacrylate). Despite well conducted antibioprophylaxy, the patient developed fever one day later due to a Klebsiella pneumoniae septicemia. Amoxicillin-clavulanate achieved a good clinical response, but a few days later Clostridium difficile colitis was documented, prompting the addition of oral Ornidazole. The FDG-PET/CT-based metabolic response assessment showed a good metabolic response consistent among lesions 2 weeks after chemotherapy administration. Unfortunately, a voluminous hepatic abscess was discovered in the left hepatic lobe (segments ll/lll), confirmed by magnetic resonance imaging (MRI). An endoscopic treatment of the abscess by cystogastrostomy was realized by the implantation of 2 double pigtail stents. Microbiologic samples and blood cultures were positive for an amoxi-clavulanate-resistant E.coli, leading to Amoxicilline-Clavulanate replacement by Ceftriaxone.

Bleeding from upper GI tumors accounts for 1–5% of all acute upper Gl hemorragies.^1,2 Selective angiography enables the precise localization of active arterial bleeding and allows selective embolization, providing definitive hemostasis in 63% to 80% of cases. Hepatic infarction and abscess after embolization have been reported in as much as 30% of the cases, with previous biliary surgery or endoscopic treatment as known risk factors

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