Varices around colostomy are infrequently reported. We describe a patient with recurrent bleeding from colostomy varices successfully managed by transjugular intrahepatic portosystemic shunt (TIPS).
Case Summary A 51-year-old man was hospitalized with a 3-month history of bleeding from colostomy. Blood often spurted from the ostomy site and the bleeding spontaneously resolved. The patient had alcoholic liver cirrhosis. Nine months previously he had laparoscopic sigmoidectomy for colonic stricture from diverticulitis. Physical examination revealed spider angiomata and icterus. Blood was seen oozing from the stoma. Laboratory data showed anemia and thrombocytopenia. Abdominal CT showed splenomegaly. Endoscopy revealed dilated veins appearing as soft bluish ridges around the stoma. Ultrasound/Doppler study demonstrated multiple large varicosities surrounding the stoma. Propranolol was administered to decrease portal venous pressure. Bleeding ceased, and the patient was discharged home. He had recurrent bleeding requiring multiple admissions and blood transfusions over the subsequent 4 months. A TIPS procedure was performed. There was no further bleeding during the ensuing 4 months.
Discussion Bleeding from varices at colostomy, ileostomy, or ileal conduit stomas, an unusual complication of portal hypertension, is a challenging problem. Stomal and peristomal varices are the result of anastomoses between the high-pressure portal venous system and the low-pressure systemic venous system around the stoma. After stoma surgery, adhesions may develop between the mesentery and abdominal wall. Episodes of serious bleeding have been reported in up to 100% of such patients. Life-threatening hemorrhage from peristomal varices is rare, with an estimated mortality rate of 3-4% per episode. Many forms of treatments have been reported. Only five cases of peristomal colostomy varices successfully treated with TIPS have previously been reported. To our knowledge this is the first report of the use of ultrasound/ Doppler study to demonstrate peristomal varices at a colostomy site.
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