Bleeding stomal varices in portal hypertension

Abstract

We report a case of a 50-year-old man with a history of liver cirrhosis and colon cancer post end colostomy presenting to the emergency department with stomal bleeding and passage of clots into the colostomy bag. The patient was treated with transjugular intrahepatic portosystemic shunt (TIPS) and concomitant embolization of the stomal varices via the TIPS shunt using N-butyl cyanoacrylate mixed with ethiodol. Although stomal variceal bleeding is uncommon, this entity can have up to 40% mortality upon initial presentation, given the challenges in diagnosis and management. Currently, there are no established standard treatments for stomal variceal bleeding. In addition, to the best of our knowledge, there are no cases in the current literature in which treatment of this entity is performed with a combination of TIPS shunt placement and N-butyl cyanoacrylate variceal embolization.

Parastomal Varices with Recurrent Bleeding in the Absence of Liver Cirrhosis

“…The parastomal varices in this patient showed focal bleeding that was controlled by applying pressure using a cotton swab. Recent case reports have shown the use of percutaneous N -butyl-2-cyanoacrylate glue injection effectively stopped bleeding from parastomal varices [ 8 ]. However, injection of N -butyl-2-cyanoacrylate glue is not approved in the United States [ 1 ].…”

“…Despite being common in patients with a colostomy, many patients and physicians are unaware of parastomal varices and the frequency of bleeding [ 2 , 8 ]. Physicians are encouraged to remove any bandages or stoma appliance to examine the surrounding skin for a purplish hue around the stomal area, which suggests presence of parastomal varices [ 8 ].…”

“…Despite being common in patients with a colostomy, many patients and physicians are unaware of parastomal varices and the frequency of bleeding [ 2 , 8 ]. Physicians are encouraged to remove any bandages or stoma appliance to examine the surrounding skin for a purplish hue around the stomal area, which suggests presence of parastomal varices [ 8 ]. However, only 25% of patients exhibit the purplish hue; physicians are encouraged to use Doppler ultrasound, contrast-enhanced CT, and portal vein venography to confirm the diagnosis for many patients with recurrent bleeding around the stoma site [ 2 ].…”

“…If bleeding remains persistent or increases in severity, reducing portal hypertension using a transjugular intrahepatic portosystemic shunt (TIPS) effectively prevents most rebleeding events from parastomal varices [ 8 ]. Specifically, only 20% of patients with parastomal varices with a history of rebleeding continued to have bleeding after the TIPS procedure [ 2 ].…”

Comparison of betablockers and endoscopic variceal band ligation (EVBL) for secondary prevention of variceal bleed in cirrhotics.

“…This reduction in mortality is caused by the availability of efficient options, such as upper GI endoscopy and EVBL, targeted pharmacological options, trans Jugular Intrahepatic Stent shunt (TIPS) and also with improvement of general measures. 5 There is always a risk of recurrence of upper GI bleed, which carries a mortality of 33%, so there must be some treatment to prevent further episodes of variceal bleed. Secondary prophylaxis includes drugs, repeated endoscopic procedures, or their combination and the use of shunts like TIPS.…”