Novel Use of Endoscopic Ultrasound to Successfully Treat Parastomal Varices with N-butyl-2-cyanoacrylate: Presidential Poster

Abstract

Purpose: Describe a novel role for endoscopic ultrasound (EUS) in the treatment of parastomal varices with N-butyl-2-cyanoacrylate (NBCA). Case Report: A 74 year old female with a hx of ulcerative colitis s/p colectomy with end ileostomy, morbid obesity, COPD (O2 dependent), and Laennec's cirrhosis was transferred to our institution for transfusion dependent ostomy bleeding. The patient had over a dozen admissions to her local hospital and required 34 units of PRBC over the last year. CT demonstrated parastomal varices with cirrhotic liver morphology. Two previous attempts at transjugular intrahepatic portosystemic shunt (TIPS) were unsuccessful due to adverse anatomy. Options were discussed with the patient. A trial of beta-blockers was thought suboptimal given her COPD. A retrial of TIPS at our institution was offered but the patient refused. Consequently, we decided to employ EUS to localize the parastomal varices and then use NBCA to obliterate them. The patient was prepped with Mg citrate overnight. First, an adult gastroscope was advanced 20 cm into the stoma. No blood was seen and the mucosa was normal with no large vessels. Subsequently, a radial echoendoscope was used to visualize two prominent parastomal varices below the mucosal surface of the ileostomy by US. Flow was confirmed with Doppler. A linear echoendoscope was then inserted. Using a 22-G FNA needle, a mixture of 0.5 ml NBCA and 1.5 ml lipoidal was injected into the varices with good immediate effect. Lack of flow was confirmed after injection by Doppler. Ex-vivo, needle and scope channel were immediately flushed with Lipoidol. A total of 5.5 ml of glue was used. The patient tolerated the procedure well, was discharged home after 3 days, and has had no further episodes of bleeding. Discussion: Parastomal varices are a known complication of stoma creation in patients with portal HTN. Established treatments for parastomal varices include TIPS and surgery. We describe a case of parastomal varices in a patient who could not undergo either of these treatment modalities. Additionally, her significant comorbidities were a relative contraindication to even medical therapy with beta-blockers. Consequently, we employed EUS-guided NBCA glue to treat her parastomal varices. Though a few cases of parastomal varices treated with glue exist in the literature, all of the previous situations have employed a direct percutaneous approach. Consequently, this is the first reported case where EUS is successfully used for visualization and obliteration of varices in this patient population. Although further evaluation is warranted, EUS appears to be a safe and important adjunct modality in the treatment of stomal varices by NBCA glue injection.