A case of peri-stomal ectopic variceal bleeding in a patient with decompensated cirrhosis treated with TIPS placement.

Abstract

Peri-stomal variceal bleeding is an underestimated complication in patients with colostomy and portal hypertension. Due to the small number of reported cases, there is currently no unified consensus on the best treatment and several options may be available. We report a case in which TIPS placement was effective. A 59-year old male with alcohol-induced cirrhosis complicated by ascites, hepatic encephalopathy and low-risk esophageal varices (MELD-Na 15, Child-Pugh C11) was referred to us in 09/19. Thereafter, his conditions greatly improved with alcohol abstinence and medical treatment. In 09/21 he presented severe anemia without acute bleeding due to adenocarcinoma of sigma without metastases. Despite severe portal hypertension (Hepatic Venous Pressure Gradient [HVPG]: 21 mmHg), the multidisciplinary team gave the indication to left hemicolectomy with colostomy based on age, clinical stability (no ascites or other complications in the previous 6 months) and relatively preserved liver function (MELD-Na 12, Child-Pugh B7). Postoperative course was regular without complications. Two months after surgery, two episodes of bleedings from colostomy needing blood transfusions occurred. Abdominal CT-scan showed peristomal venous varices (Figure 1A). In consideration of the recurrent bleedings and the absence of endoscopic and endovascular options, a transjugular intrahepatic portosystemic shunt (TIPS) was placed in 03/22 inducing a HVPG fall to 9 mmHg. After one month a CT-scan showed a decompression of the peristomal varices (Figure 1B). To date (12/22) the patient did not present new episodes of bleeding or TIPS-related complications.