radiation - induced hemorrhagic gastritis is a serious complication and is very difficult to manage . we successfully treated a case of intractable gastric bleeding induced by postoperative radiation using oral prednisolone . a 59-year - old woman presented with dark urine and generalized pruritus in april 2012 . previous to this , she had undergone total abdominal hysterectomy and bilateral salpingoophorectomy for uterine cervical cancer in february 1993 and had undergone a modified radical left mastectomy for left - sided breast cancer in september 2008 . after confirmation of the klatskin tumor , a radical operation was performed on april 20 , 2012 . the operation consisted of resection of the left lobe of the liver and radical extrahepatic bile duct resection with roux - en - y heapticojejunostomy , combined with portal vein partial resection and re - anastomosis . the tumor was pathologically diagnosed as adenocarcinoma consistent with a klatskin tumor that had directly invaded the liver . in addition , the tumor was present in the portal vein , lymphatic area , cystic duct , and perineural area . the distal bile duct resection margin was focally involved , and the liver parenchymal resection margin was very close . because of these high risk pathological findings , postoperative three dimensional conformal radiotherapy was performed from may 22 , 2012 , to july 3 , 2012 , with a total radiation dose of 54 gy over 30 fractions . the antrum of the stomach was also included in the radiation treatment volume ( fig . 1 ) . mean radiation dose of the stomach was 37.7 gy , and the maximum radiation dose to the stomach antrum was 55.1 gy . in the dose volume histogram ( fig . 2 ) , 30% of stomach volume received a radiation dose higher than 50 gy , and the stomach antrum received a greater part of the overall radiation burden to the stomach . cisplatin and 5-fluorouracil systemic chemotherapy was administered concurrently with radiation therapy . after the end of radiation therapy , the patient was admitted on november 13 , 2012 ( 100 days after completing radiotherapy ) with melena and anemia . the results of blood coagulation tests ( prothrombin time [ pt ] international normalization ratio 1.11 , pt % 80.0 , pt sec 11.8 , activated partial thromboplastin time 35.7 seconds ) were normal . she did not take any anticoagulant or antiplatelet medications , and did not have a history of bleeding disorder . on abdominopelvic computed tomography , no bleeding focus was found throughout the small and large bowels or at the anastomosis site . a proton pump inhibitor was initiated at admission , but the melena persisted . between november 13 and 15 , follow - up egd performed on november 19 showed no change in hemorrhagic antral mucosa , during which epinephrine was injected . however , the melena persisted , and transfusion of 3,200 ml of additional packed rbc was performed between november 20 and 30 . because the area of bleeding was confined to the highly irradiated antral area and various measures were not successful , we concluded that the hemorrhagic gastritis was due to radiation therapy . therefore , we decided to try oral steroid treatment , which ( 10 mg prednisolone four times / day ; total daily dose 40 mg ) was initiated on november 30 . the melena stopped after six days of treatment with oral prednisolone without correction of thrombocytopenia . between december 1 and 5 , the prednisolone dose was tapered to 20 mg daily ( 5 mg four times / day ) . egd performed on december 10 , 2012 ( treatment day 11 ) showed discrete blood clots and scanty hemorrhagic mucosa in the pyloric antrum without a definite bleeding focus and markedly decreased oozing compared to the previous endoscopic study ( fig . the daily steroid dose was tapered to 10 mg ( 5 mg bid ) on treatment day 11 . after treatment day 14 , the daily dose was tapered to 5 mg and maintained for two months . for the month following cessation of melena , a total of 1,120 ml rbcs were transfused . since then , the patient has not experienced subsequent bleeding episodes , and did not require additional transfusion . yoon et al .   reported on three patients with national cancer institute ( nci ) common toxicity criteria grade iii or higher gastrointestinal bleeding or ulceration among 51 patients who underwent radiation therapy for treatment of lymph node metastases from hepatocellular carcinoma . radiationinduced hemorrhagic gastritis can lead to significant gastric bleeding and is usually refractory to treatment , which makes it a potentially lethal complication . successful treatment outcomes for patients with radiation - induced hemorrhagic gastritis are presented only as case reports due to the rarity of this complication and the refractoriness to treatment . high total doses and fractional dose appear to be the main risk factors for gastric injuries and may be potentiated by the concurrent administration of fluorouracil . the patient in the current case had received a relatively high dose of radiation for the positive surgical resection margin , with concurrent administration of 5-fluorouracil . injury to the stomach from radiation therapy can result in a form of hemorrhagic gastritis , characterized by acute vasculopathy , which may progress to obliterative endarteritis with mucosal ischemia and ulceration . normal tissue in proximity to a targeted neoplasm may develop ballooning degeneration with ischemia and cell death . hyperbaric oxygen therapy can serve as a stimulus for development of neovascularity in these tissues . a few cases of successful hyperbaric oxygen treatment have been reported , however , hyperbaric oxygen therapy is not widely available . reported successful use of argon plasma coagulation ( apc ) for hemostasis of widely spreading radiation hemorrhagic gastritis . as the application of apc must be limited to the surface mucosa , those authors suggested that apc is an easy and effective treatment for radiation hemorrhagic gastritis . .   also reported on a patient with hemorrhagic gastritis induced by external radiotherapy for pancreatic cancer who was treated successfully using apc . wada et al .   also described a case of effective treatment with apc in a similar patient . unfortunately , in our patient , the bleeding from antral mucosa was diffuse , and laser coagulation was ineffective . on the other hand , staiano et al . reported successful treatment of radiation - induced hemorrhagic gastritis using endoscopic band ligation . because conservative treatment is usually ineffective , gastrointestinal radiation injuries are often treated surgically . reported a case of hemorrhagic gastritis induced by radiotherapy , which was successfully treated with total gastrectomy . yeung et al .   also reported a case of recurrent hemorrhagic gastritis successfully treated by surgical resection . our patient was very fragile after suffering three major operations for three different cancers during her lifetime ; thus , surgical resection of a heavily treated stomach appeared to be difficult and dangerous . because bleeding persisted despite various measurements and because of large amounts of transfusion required , spontaneous healing was not likely in this patient . we tried oral prednisolone treatment , as the effect of steroid is well known for radiation - induced inflammation in radiation pneumonitis and severe radiation proctitis . in our case , the melena showed dramatic improvement after only six days of treatment with oral prednisolone without correction of thrombocytopenia . inaba et al .   reported a case of hemorrhagic radiation gastritis after chemoradiation therapy for peritoneal lymph node metastasis of esophageal carcinoma , which was successfully treated with repeated intra - arterial steroid infusions . zhang et al .   recently reported a case of hemorrhagic radiation gastritis successfully treated with oral prednisolone , with outcomes similar to those of our case . although the exact nature of radiation - induced gastritis is not known , it is presumed to be an inflammatory process resulting in mucositis . steroid is thought to have an antiinflammatory action by preventing the liberation of arachidonic acid from cell membranes , decreasing neutrophilic phagocytosis and by diminishing adherence and chemotaxis of neutrophils , eosinophils , and monocytes , subsequently leading to inhibitions of the release of other inflammatory cytokines . a reduction in neutrophil recruitment and local cytokine production , and improvements in microcirculation by reversal of capillary permeability have been proposed as mechanisms responsible for the effects of steroid in inflammatory bowel disease . reported that the mucosal levels of cytokines such as interleukin ( il)-2 , il-6 , and il-8 were significantly increased in the colon among patients with radiation proctitis . anti - inflammatory functions of prednisolone may reduce gastric mucosal damage and degeneration as well . based on this case , we believe that oral prednisolone treatment can be tried as a first treatment for potentially life threatening radiation - induced hemorrhagic gastritis . we expect that more case reports of treatment success for this refractory complication will substantiate our results in the future .
radiation - induced hemorrhagic gastritis is an intractable and dangerous condition . 
 we describe a 59-year - old female patient with radiation - induced hemorrhagic gastritis . 
 the patient underwent postoperative radiation therapy with a dose of 54 gy in 30 fractions after a radical operation for a klatskin tumor . 
 radiation volume included the gastric antrum . 
 approximately three months after radiation therapy , she was admitted for melena and anemia . 
 esophagogastroduodenoscopy showed an area of bleeding in the gastric antrum that was so diffuse that effective laser coagulation was not feasible . 
 after failure of various treatments and transfusion of 7,040 ml of packed red blood cells , we successfully stopped the hemorrhage using oral prednisolone treatment . 
 based on this case , we think that oral prednisolone treatment can be tried as a first treatment for potentially life - threatening radiation - induced hemorrhagic gastritis .