S2138 TACE-Induced Ischemic Colitis

Introduction: Transarterial chemoembolization (TACE) is a locoregional treatment used in patients with hepatocellular carcinoma (HCC). This therapy entails injecting a chemotherapeutic agent into a branch of the hepatic artery supplying blood to the tumor while cutting off blood supply through particle embolization. This procedure may be utilized in a patient who is not a candidate for surgical resection or as a bridge to liver transplantation. Here we present a case of a ischemic colitis in the setting of a recent TACE. Case Description/Methods: A 65-year-old female with history of HCC underwent an outpatient TACE procedure for a 3.6 cm liver lesion. Soon after the procedure the patient complained of severe abdominal pain and was admitted. On day 2 of hospitalization, she developed significant bright red blood per rectum. Computed tomography (CT) demonstrated mild wall thickening and pericolonic fat stranding in the ascending colon concerning for acute colitis. Lactic acid was elevated at 5.8 mmol/L (normal < 2). Colonoscopy demonstrated multiple ulcers and erythema stretching from the cecum to descending colon suggestive of ischemic colitis. Biopsies demonstrated superficial mucosal erosion and necrosis, crypt atrophy, and lamina propria hemorrhage with hyalinization, consistent with acute ischemic colitis. CT angiography demonstrated a patent abdominal aorta and all major branches. The patient was treated conservatively without further episodes of hematochezia and was discharged home (Figure). Discussion: Postembolization syndrome is the most common adverse effect of TACE, which occurs in 60 to 80 percent of patients. This has been reported to be related to either tumor necrosis or due to ischemic damage to normal liver parenchyma. One case of gastrointestinal ulceration has been reported after TACE. To date, there has been no reported case of ischemic colitis after TACE. This presentation of ischemic colitis in our patient may be due to regurgitation of embolized particles into superior mesenteric arterial circulation leading to hypoperfusion of the colon, resulting in ischemic colitis. One should consider this presentation on the differential diagnosis in a patient with hematochezia after TACE.Figure 1.: Ascending and transverse colon demonstrating multiple ulcers and erythema suggestive of ischemic colitis on colonoscopy.