Direct Percutaneous Embolization of Peristomal Ileostomy Varices in an Emergency Setting

Abstract

Patients with liver disease and portal hypertension who have had surgical formation of an abdominal stoma are at risk of developing peristomal varices. These varices have a predilection for bleeding. Ideally, portal decompression via TIPS procedure is performed, with or without direct embolization of the bleeding varix. When TIPS is not an appropriate option due to significant liver disease and hepatic encephalopathy there are other approaches to treat peristomal variceal hemorrhage. We report the embolization of such a varix via direct percutaneous puncture under ultrasound guidance when portal decompression was not an appropriate option.

Transcatheter embolization for stomal varices: A report of three patients

“…Some case reports have described resolution of bleeding under ultrasound-guided direct puncture of varices [10] , [11] , [12] . In 7 cases reported by Thouveny, patients achieved a mean nonbleeding period of 11.6 months without complications [10] .…”

A Novel Approach for Management of Bleeding Stomal Varices: A Case Report of Ultrasound-Guided Percutaneous Sclerotherapy

“…There are multiple strategies to treat a variceal ostomy bleed including local control (manual pressure or pressure dressings, suture ligation, sclerotherapy, intravascular coil, or glue embolization), portal vein decompression with TIPS, and liver transplant. 1-9 In the majority of cases, local therapy is used as first-line treatment as demonstrated in our patient who was successfully treated with sclerotherapy. We would like to highlight the possibility of ultrasound-guided percutaneous sclerotherapy of ostial varices with sodium tetradecyl sulfate though care is needed to prevent stomal damage.…”

“…Literature review supports use of direct pressure, suture ligation, intravascular coil, glue embolization, and sclerotherapy in the acute variceal bleed setting. [1][2][3][4][5][6][7][8][9] To our knowledge, there are no reports of direct ultrasound-guided percutaneous injection of sodium tetradecyl sulfate to treat bleeding abdominal wall stomal varices and this case highlights the safety and feasibility of such a technique, particularly when the patient has significant contraindications for TIPS.…”

“…Current literature related to this topic is mostly limited to case reports, case series, and literature review but, in general, recommends the use of TIPS in conjunction with local control of bleed to provide greatest reduction in risk of rebleeding outside of liver transplant. 1,4,5 However, it should be noted that rebleed rates in patients who have received TIPS can still be as high as 21% to 37%, highlighting the importance of local control techniques. 6 More research is needed to assess which treatment strategy provides the best short- and long-term outcomes for patients presenting with ileostomy variceal bleeding, particularly those with contraindications to TIPS or those who rebleed after TIPS.…”

“…Only 5% of variceal bleeds are reported to be from an ileostomy varix. 1 Mortality from stomal variceal bleeding, though 10-fold lower than esophageal variceal bleeding, is still approximately 3% to 4% per occurrence. 2 Conservative local therapies can have a rebleeding rate as high as 70%, commonly requiring blood transfusions and hospitalization when they occur.…”