Rare case of a giant duodenal ulcer penetrating the pancreas during antiangiogenic treatment

• Published in: BMJ case reports 2019-05, Vol.12 (5), p.e228612
• Main Authors: Palmela, Carolina, Gouveia, Catarina, Fidalgo, Catarina, Ferreira, Alexandre Oliveira
• Format: Article
• Language: English
• Subjects: Angiogenesis; Angiogenesis Inhibitors - administration & dosage; Angiogenesis Inhibitors - adverse effects; Carcinoma, Renal Cell - drug therapy; Case reports; Colorectal cancer; Duodenal Ulcer - diagnostic imaging; Duodenal Ulcer - pathology; Duodenal Ulcer - therapy; Electrocoagulation; Endoscopy; Gastrointestinal Hemorrhage - chemically induced; Gastrointestinal Hemorrhage - therapy; Gastroplasty; Health surveillance; Hemoglobin; Humans; Inhibitor drugs; Kidney cancer; Melena; Meta-analysis; Metastasis; Middle Aged; Pancreas - diagnostic imaging; Pancreas - pathology; Patients; Proton Pump Inhibitors - therapeutic use; Pylorus - pathology; Pyrimidines - administration & dosage; Pyrimidines - adverse effects; Sulfonamides - administration & dosage; Sulfonamides - adverse effects; Surgery; Syncope; Systematic review; Targeted cancer therapy; Treatment Outcome; Ulcers; Unexpected Outcome (Positive or Negative) Including Adverse Drug Reactions; Vascular endothelial growth factor; Veins & arteries
• ISSN: 1757-790X; 1757-790X
• DOI: 10.1136/bcr-2018-228612

We report a case of a patient with renal cell carcinoma on pazopanib, who presented with severe upper gastrointestinal bleeding. Endoscopy showed a giant bulbar ulcer with a visible vessel of 4 mm. Due to unavailability of surgical rescue backup, large calibre vessel treatment was delayed. Endoscopy was repeated after 48 hours and showed a reduction in the vessel diameter. Endoscopic adrenalin injection and electrocoagulation were performed. However, the vessel increased in size and became pulsatile. The patient was operated, confirming a giant bulbar ulcer penetrating the pancreas with active bleeding from the gastroduodenal artery. Pazopanib therapy was suspended, and the patient is asymptomatic. Antiangiogenic treatment has been associated with gastrointestinal bleeding, perforation and fistulisation. Although we cannot confirm the causal association between the penetrating ulcer and pazopanib, the absence of Helicobacter pylori infection or non-steroidal anti-inflammatory drugs, and the reported cases of gastrointestinal bleeding during these therapies favour a possible association.