2496 Management of Recurrent Ectopic Variceal Bleeding in Ileal Conduit With TIPS

Abstract

INTRODUCTION: The simplest classification of portosystemic collateral veins classifies all non-esophagogastric varices as ectopic varices. Ileal varices are an example of ectopic varices formed from the ileal veins (tributaries of SMV) and draining into the mesenteric vessels. We present a case of an ileal conduit complicated by recurrent ectopic variceal bleeding amenable to a transjugular intrahepatic portosystemic shunt (TIPS) procedure. CASE DESCRIPTION/METHODS: A 45 year-old male with Hepatitis C and alcohol related cirrhosis complicated by portal hypertensive gastropathy and non-bleeding esophageal varices (EV) presented with a one month history of recurrent hematuria via his ileal conduit. He had a history of colon cancer stage IIB status post cystoprostatectomy and sigmoidectomy with ileal conduit in 2013. He had required three hospitalizations for his recurrent bleeding, needing multiple blood transfusions. Previous workup included a CT abdominal angiogram showing porto-systemic collaterals without active extravasation of contrast, an ileal conduit loopogram showing good functionality, and an ileal conduit endoscopy showing no visible ileal varices or active bleeding. On admission to our institution, he was hemodynamically stable and did not required additional blood transfusions. An abdominopelvic CT scan showed a normal ileal loop conduit and again small mesenteric portosystemic collaterals were evident. There was a high suspicion for ectopic varices in the ileal conduit, and a TIPS procedure was performed. A pre-TIPS portogram showed the presence of large ectopic ileal varices filled with contrast with resolution after TIPS placement. TIPS was successful with decrease of hepatic venous pressure gradient from 18 mmHg to 9 mmHg. He was discharged after TIPS procedure and has not required repeat hospitalization for hematuria. DISCUSSION: Ectopic varices account for up to 5% of variceal hemorrhage, and there is no consensus for therapeutic management. This patient had ileal conduit varices causing recurrent clinically significant hematuria. TIPS placement successfully controlled his recurrent ectopic variceal hemorrhage.