Successful Management of Peristomal Variceal Bleeding with Coil Embolization in a Patient with Decompensated Cirrhosis

Abstract

Peristomal varices occasionally form in cirrhotic patients who have surgically created anastomoses and stomas. Variceal hemorrhage in this group carries an estimated mortality of 3%- 4% per episode, compared to the 30%- 40% mortality with esophageal variceal bleeding. We present a 59 year old African American male with Hepatitis C and Child's B cirrhosis, 5 years s/p colostomy for colon cancer, diabetes, end stage renal disease, peripheral vascular disease with bilateral amputations who presented with recurrent episodes of active bleeding in his colostomy bag over the past year. The patient was hemodynamically stable on presentation but had to be transfused one unit of packed RBC's. He had a Hb of 8.1 gm/dl with an INR of 1.4. His liver function tests were significant for an albumin of 1.1 gm/dl. An endoscopy done one month ago showed hemorrhagic esophagitis with duodenal polyps and no evidence of esophageal or gastric varices. A Colonoscopy through the colostomy site showed diverticulosis. An abdominal CT revealed a cirrhotic liver, splenomegaly, and moderate ascites with confluent veins around stoma site. The etiology of his bleeding was thought to be due to peristomal varices secondary to portal hypertension. Surgical intervention or Transjugular intrahepatic portosystemic shunt (TIPS) placement were not suitable options in him secondary to multiple co morbidities and the risk of encephalopathy and liver failure. Interventional radiology attempted coil embolization of these peristomal varices. Access into the portal system was obtained using a percutaneous portal transhepatic puncture. Inferior mesenteric venogram demonstrated enlarged IMV with hepatofugal flow into varices around the colostomy site. The main varix was coil embolized with four 8 mm nester coils. The post coil embolization venogram revealed a collateral vessel supplying the varix to the stomal site. Two coils were then placed at the origin of this vessel. The catheter was removed with no post procedure complications. The patient had no further episodes of bleeding after the embolization and continues to do well at the 3 month follow up. Stomal variceal hemorrhage has a lower mortality compared to esophageal variceal bleeding. TIPS is another modality to control bleeding from ectopic/stomal varices. Coil embolization with or without TIPS should be considered as a therapeutic option in stomal variceal bleeding especially in high-risk surgical patients.