Successful treatment of hemorrhagic radiation esophagitis with radiofrequency ablation

A 78-year-old man, with a history of T2N0M0 esophageal adenocarcinoma treated with chemoradiotherapy 2 years before, was referred to our department with recurrent upper gastrointestinal bleeding (hemoglobin level of 8.8 g/dl), attributed to radiation esophagitis. He had been admitted three times before for red blood cell transfusion and endoscopic treatment with argon plasma coagulation. Initial esophagogastroduodenoscopy showed diffuse telangiectasias of the lower esophagus and gastroesophageal junction with signs of recent bleeding ([Fig. 1 a]). Radiofrequency ablation (RFA) of the lower esophagus and gastroesophageal junction was performed using a double 10 J/cm² ablation with a 360° Express balloon catheter (Medtronic, Minneapolis, Minnesota, USA) ([Video 1], [Fig.1 b]), followed by double-dose proton pump inhibitors. Despite no recurrent digestive bleeding, persistent iron deficiency anemia prompted repeat esophagogastroduodenoscopies, including two RFA treatment sessions every 6 months, using a triple 12 J/cm² RFA application with a focal Halo 90 catheter. The 15-month follow-up esophagogastroduodenoscopy showed a significant regression of the esophageal telangiectasias ([Fig. 1 c]). No recurrent bleeding occurred and hemoglobin level remained stable.

Fig. 1 a Initial esophagogastroduodenoscopy showing diffuse telangiectasias and signs of recent bleeding. b Radiofrequency ablation of the lower esophagus with a 360° Express balloon catheter. c Endoscopic follow-up after three radiofrequency ablation treatment sessions – ablation of the majority of the esophageal telangiectasias.

Video 1 Radiofrequency ablation for the treatment of radiation esophagitis.

Radiation esophagitis occurs in up to 42 % of patients after radiation therapy for lung, breast, or esophageal carcinomas or mediastinal lymphomas [1]. Whereas acute radiation esophagitis typically presents with self-limiting dysphagia and odynophagia, chronic radiation esophagitis may lead to complications such as bleeding of esophageal telangiectasias, stenosis, impaired motility or esophagorespiratory fistula. Esophageal telangiectasias are generally managed by argon plasma coagulation (APC). As for other angioectasias occurring elsewhere in the gastrointestinal tract (gastric antral vascular ectasia, radiation proctitis), radiofrequency ablation might be offered as a rescue therapy [2]. To our knowledge, this is the second patient with radiation esophagitis treated with RFA [3], and the first with RFA alone. The favorable long-term evolution suggests that RFA is a feasible, safe, and promising treatment modality for radiation esophagitis with refractory bleeding.

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• References

• 1 Afifi A, Powerski M, Jechorek D. et al. Radiation-induced damage in the upper gastrointestinal tract: clinical presentation, diagnostic tests and treatment options. Best Pract Res Clin Gastroenterol 2020; 48–49: 101711
• 2 Becq A, Camus M, Rahmi G. et al. Emerging indications of endoscopic radiofrequency ablation. United European Gastroenterol J 2015; 3: 313-324
• 3 Monino L, Garces-Duran R, Deprez PH. et al. Upper gastrointestinal bleeding due to mixed adenoneuroendocrine carcinoma and radiation esophagitis treated with cap-mucosectomy combined with radiofrequency ablation. Endoscopy 2021;