Massive gastrointestinal hemorrhage and iodine-125 seed migration due to hepatogastric fistula: a case report and literature review

Background: Hepatogastric fistula (HGF) is an uncommon occurrence that can be associated with various medical conditions. The primary causes typically involve peptic ulcer disease, infections (such as pyogenic, amoebic or tuberculosis), or iatrogenic factors (like post transarterial chemoembolization or radiotherapy). Massive gastrointestinal hemorrhage following HGF is extremely rare, with iodine-125 (¹²⁵I) seed migration to the stomach through HGF not previously documented. This report explores this unique case and reviews other recent instances of rare gastrointestinal hemorrhage due to HGF.

Case description: A 32-year-old man with chronic B viral hepatitis underwent emergency surgery to control bleeding due to hepatocellular carcinoma (HCC) rupture. One month postoperatively, an active residual tumor (44 mm × 33 mm) was found in the caudate lobe of the liver. The patient was admitted for percutaneous microwave coagulation therapy (PMCT) and ¹²⁵I seed implantation sequentially. No postoperative discomfort was observed. Subsequent intrahepatic HCC distant recurrences were successfully managed using PMCT and systemic treatments (molecular targeted drug and checkpoint inhibitor). Twenty months after the initial seed implantation in the caudate lobe, the patient was referred again owing to intrahepatic tumor recurrence in the right lobe and underwent repeat PMCT and ¹²⁵I seed implantation. Two days after the second ¹²⁵I seed implantation, the patient presented with severe upper gastrointestinal bleeding and epigastric pain. The caudate lobe was in communication with the lesser curvature of the stomach, resulting in the formation of the HGF. Subsequently, intermittent massive gastrointestinal hemorrhage occurred, and seed implantation in the caudate lobe migrated to the stomach through the HGF. Endoscopy and imaging confirmed HGF and seed migration to the stomach, and surgery was successfully performed.

Conclusions: A thorough clinical medical history and heightened vigilance are essential for diagnosing and managing this rare complication.