Bleeding Stomal Varices: Case Series and Systematic Review of the Literature

Abstract

Bleeding stomal varices are a common problem in patients with surgical stomas and portal hypertension, and remain difficult to diagnose and manage. We identified all patients at our institution with bleeding stomal varices from 1989 to 2004. We surveyed all patients undergoing ileal pouch-anal anastomosis from 1997 to 2007 for bleeding anastomotic varices. Finally, we performed a systematic review of the literature focusing on diagnosis and treatment of bleeding stomal varices that included 74 English language studies of 234 patients. We identified 8 patients with bleeding stomal varices. Recognition of stomal varices typically was delayed, particularly when failing to examine the ostomy without the appliance. Stomal variceal bleeding was confirmed by Doppler ultrasound or angiographic imaging. Simple local therapy usually stopped bleeding, albeit temporarily. Sclerotherapy was effective, but at the expense of unacceptable stomal damage. Decompressive therapy was required for secondary prophylaxis, including transjugular intravascular transhepatic shunts (2 patients), surgical portosystemic shunts (2 patients), and liver transplantation (1 patient). No patient with an ileal pouch-anal anastomosis developed anastomotic bleeding from varices. Primary prevention of bleeding stomal varices requires avoidance of creating enterocutaneous stomas in patients with portal hypertension. Careful inspection of the uncovered ostomy is essential for bleeding stomal varices diagnosis. Once identified, conservative measures will stop bleeding temporarily with definitive therapy required, including transjugular intravascular transhepatic shunts, surgical shunts, or liver transplantation.