S2111 Recurrent Bleeding From Peristomal Varices: A Management Dilemma

Abstract

INTRODUCTION: Gastroesophageal varices are seen in the setting of portal hypertension, however, ectopic varices may arise elsewhere such as around ostomy site. These account for more severe complications as there is no standardized management for them. Peristomal varices can lead to massive bleeding due to an increase in the portal pressure gradient and resulting mortality in as high as 40% cases (higher in cases with rebleeding). CASE DESCRIPTION/METHODS: A 65 year old male with a history of rectal adenocarcinoma status post colostomy four years prior to admission, peristomal varices status post suture ligation and sclerotherapy that re-bled and underwent coiling embolization was admitted to the hospital for acute severe abdominal pain, fatigue and heavy bleeding into his ostomy pouch for 2 days. Lab work showed a hemoglobin of 6.0 g/dL (9.5 g/dL one month prior). Physical exam demonstrated bright red blood from the stomal edge and clots in the ostomy pouch. A CT abdomen showed extensive varices in the perigastric region. Colonoscopy showed bleeding from stomal varices in the 5 o'clock position. Patient underwent percutaneous embolization of the superficial and deep varices around the edge of stoma which resolved the bleed. However, three months later, patient presented to the hospital with rebleeding, progressive metastasis of the rectal adenocarcinoma and worsening portal hypertension failing medical management. Due to worsening prognosis and recurrent bleeding, patient opted for hospice care. DISCUSSION: Ectopic varices account for 4–5% of variceal bleeds and the mortality risk for an initial episode is as high as 40% as it is often difficult to differentiate ectopic variceal bleeding from other causes of lower gastroesophageal bleeds causing a delay in management. Our patient had recurrent stomal variceal bleeds and had become transfusion dependent. Moreover, his initial non-invasive management ended in recurrent bleeding which occurs in 75% of cases. All patients do achieve full resolution even after coiling embolization as new variceal formation occurs. Treatment options can range from conservative management to invasive procedures. Transhepatic coil embolization or transjugular transhepatic approach to cease the bleeding are the proposed treatment modalities. However, this case presents a management dilemma for such patients due to differing management modalities and exemplifies the need for the establishment of a standard protocol.Figure 1.: Colonoscopy displaying area of bleed.Figure 2.: status post coil embolization.