Novel Use of Endoscopic Ultrasound and Injection of Sclerosant for the Treatment of Bleeding Stomal Varices

Abstract

Purpose: An 82-year-old male presented to the ED with large volume red blood from his ileostomy. His PMH was significant for a total proctocolectomy with end-ileostomy 8 years prior due to diverticulitis. He had similar presentations multiple times over the past few years with numerous ileoscopies and EGDs. No definite source had been identified. At presentation, hemoglobin was 5 gm/dL with symptoms of weakness and fatigue. Chemistry and coagulation panel were unremarkable. Physical exam was remarkable for red blood in the ostomy bag. There had been no report of preceding melenic stools,change in ostomy output, history of NSAID use or upper GI complaints. EGD was normal. Ileoscopy revealed no intraluminal bleeding source, but a small oozing area at the inferior margin of the ostomy was seen. Surgical evaluation was obtained and the area was treated with silver nitrate with successful hemostasis. Forty eight hours later, the patient had a repeat episode of clinically significant stomal bleeding. Peristomal Doppler ultrasound revealed prominent vessels in the abdominal wall adjacent to the ostomy opening. With concomitant Stage IV chronic kidney disease, the patient was unable to undergo a contrast enhanced CT or MR. As a result of this and continued, clinically significant bleeding, the patient underwent curvilinear EUS through the stoma. Five cm proximal to the stomal opening, a prominent, dilated vessel was seen. Doppler confirmed venous flow and using a 19G needle the varix was successfully injected with 5% ethanolamine. Repeat doppler post-injection confirmed absence of flow. The patient was discharged 48 hours later and has experienced no further bleeding over the last 9 months. Stomal varices are a rare, but clinically important cause of stomal bleeding. Unlike other ectopic varices throughout the GI tract, stomal varices have traditionally not been amenable to endoscopic treatment due to location exterior to the bowel wall. Historically, treatment included external compression, and percutaneous, blind injection of sclerosant. Percutaneous therapy is limited due to high risk for stomal breakdown/stenosis, ulceration and possible blind injection of a high pressure varix. Currently, the mainstay of therapy for recurrent bleeding includes decompressive procedures such as TIPS or other shunting procedures. These invasive procedures have systemic consequences and risk of their own. We describe a novel approach utilizing therapeutic EUS to treat bleeding stomal varices which appears both safe and efficacious in this challenging clinical situation. Further study is warranted before this modality can be recommended for widespread clinical use.