Ectopic Stomal Varices in Chronic Liver Disease.

CASE REPORT

A 58-year-old man with nonalcoholic steatohepatitis-related chronic liver disease and a history of rectal malignancy requiring total proctocolectomy with ileostomy presented with profuse bleeding from the ileostomy site. He had previously presented with recurrent variceal bleeding, which had been managed with variceal banding and beta-blocker therapy. Retrograde transvenous obliteration had also been performed 12 years ago for large fundal varices.

Clinical examination showed active ooze from the stoma site (Figure 1). Contrast-enhanced computed tomography revealed large ectopic stomal varices communicating with the superior mesenteric vein and right iliac vein (Figure 2). His liver synthetic function was well preserved with a model for end-stage liver disease score of 9. He was initially resuscitated with blood transfusion, local compression, and terlipressin infusion. In view of stable liver function, he underwent the transjugular intrahepatic portosystemic shunt (TIPS) procedure along with transvenous coiling of ectopic varices. Stomal bleeding settled with this treatment, and contrast-enhanced computed tomography performed 2 months after the episode showed a patent TIPS stent with a drastic reduction in the size of ectopic stomal varices (Figure 3).

Figure 1.

Showing the ileostomy with bluish red areas suggestive of varices (white arrow).

Figure 2.

Contrast-enhanced computed tomography reconstruction in the portal phase at presentation showing the large peristomal varices (yellow arrow) communicating with the superior mesenteric vein and small connecting veins draining into the right iliac vein.

Figure 3.

Contrast-enhanced computed tomography reconstruction in the portal phase, 2 months after the transjugular intrahepatic portosystemic shunt and transvenous coiling showing significant reduction and obliteration of peristomal varices.

Bleeding from parastomal varices is an uncommon site of portal hypertension-related bleeding.[1] Compression dressings, variceal suture ligation, and sclerotherapy can temporarily control bleeding but are associated with a high risk of rebleed.[2] Coil embolization may serve as an alternative in patients not suitable for TIPS, but the risk of recurrence still limits its use.[3] TIPS can be lifesaving and is the treatment of choice in compensated patients with chronic liver disease complicated with bleeding stomal varices.[4]

DISCLOSURES

Author contributions: P. DinuAbirami wrote and approved the article. MS Reddy reviewed the literature and revised the article for intellectual content. J. Varghese edited the article and is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.