3553 Sclerotherapy for stomal varices: bleeding controlled.

Abstract

Sclerotherapy is one of the standard protocols available for esophageal varices to control bleeding and reduce risk of re-bleeding. It's utility is less clear in other vascular lesions. Control of bleeding in patients (PTS) with ileostomy site stomal varices is directed at lowering filling pressure by shunting portal hypertensive blood away from bleeding collateral vessels. This is more difficult in PTS with portal vein thrombosis.We describe use of ultrasound guided sclerotherapy in five PTS to control stomal variceal bleeding. All had ileostomies during total colectomy for ulcerative colitis. Two PTS had developed pancreatic cancer decades after surgery and both had portal vein thrombosis, a complication of the malignancy. TECHNIQUE: All PTS were treated by a single care provider. PTS were NPO for eight hours before ultrasound, to reduce ostomy output. The stomal site was photographed before treatment was initiated. Venous and arterial collateral vessels were mapped out around the stoma to define high flow conduits with the bleeding site. Mid-clavicular line was defined as 12:00. Initial site selected was vessel closest to the active bleeding site. Preference was to vessels >3 mm in diameter. Direction of flow did not affect choice of vessel. The site was injected while compressing the vessel to prevent flow away from the stoma, thereby encouraging the sclerosant to propagate toward the stoma. All injections were inside vessels, not around margins of vessels. Treatments were at six week intervals, or PRN if bleeding developed. PTS were followed to demise or until liver transplant(Tx). RESULTS: Five PTS were treated. Female to male ratio was 2:3. Ages were 58-78 yrs. Two to six treatments were required to demonstrate loss of vessels >1.5 mm in diameter. Transfusion requirements varied between 5 & 26 units per yr. before sclerotherapy, with a decrease to 0-4 units per year after completion. One patient had bleeding from esophageal varices during followup period. One patient awaits a Tx while one has already undergone Tx. The 2 PTS with pancreatic cancer and portal vein thrombosis lived 4 & 6 months respectively, after completing therapy. Each required 2 treatment cycles. CONCLUSION: Stomal varices can be treated successfully with sclerosing therapy. Access to the vessel in continuity with the stoma bleeding site requires ultrasound guidance. This therapy is indeed worthwhile and effective in controlling ileostomy stomal bleeding.