Transjugular intrahepatic portosystemic shunt for bleeding stomal varices associated with chronic portal vein occlusion: long-term angiographic, hemodynamic, and clinical follow-up

Bleeding duodenal varices urgently treated with TIPS and coil embolization in a patient with cirrhosis: A rare case

Duodenal varices are ectopic varices that can cause severe and life-threatening gastrointestinal bleeding. Diagnosis and treatment of ectopic varices is challenging, because endoscopy is often unproductive in detecting and treating ectopic varices. Interventional radiology appears as an alternative in this setting, thanks to its important role in treating the bleeding caused by ectopic varices and in preventing rebleedings. We present an interesting case of bleeding ectopic varices in a male 62-years-old cirrhotic patient (Child-Pugh B8). The patient presented with hemorrhagic shock caused by massive melena. CT angiography showed intraluminal blood and identified the source of bleeding as an ectopic varicose vein draining into the superior mesenteric vein. Interventional radiology approach was the only applicable one to reach and effectively treat the source and cause of bleeding by TIPS placement and embolization of the collateral feeding at the same session

Stomal Bleeding: Assessment, Management and a Case Study of Caput Medusae

How to assess and treat an ostomate presenting with bleeding from their stoma or peristomal skin

Recent developments in the field of vascular liver diseases

Knowledge in the field of vascular liver disease is continuously expanding. The present update will discuss recent data on i) the Abernethy malformation in adults; ii) portal vein thrombosis in cirrhosis; iii) advancing expertise in recanalization of the portal vein and iv) experience in using direct oral anticoagulants in the field of vascular liver disease.

Case Series Regarding Parastomal Variceal Bleeding: Presentation and Management

Parastomal variceal bleeding (PVB) is a serious complication occurring in up to 27% of patients with an ostomy and concurrent cirrhosis and portal hypertension. The management of PVB is difficult and there are no clear guidelines on this matter. Transjugular intrahepatic portosystemic shunt (TIPS), sclerotherapy, and /or coil embolization are all therapies that have been shown to successfully manage PVB. We present a case series with five different patients who had a PVB at our institution. The aim of this case series is to report our experience on the management of this infrequently reported but serious condition. We also conducted a systemic literature review focusing on the treatment modalities of 163 patients with parastomal variceal bleeds. In our series, patient 1 had embolization and sclerotherapy without control of bleed and expired on the day of intervention due to hemorrhagic shock. Patient 2 had TIPS in conjunction with embolization and sclerotherapy and had no instance of rebleed 441 days after therapy. Patient 3 did not undergo any intervention due to high risk for morbidity and mortality, the bleed self-resolved and there was no further rebleed, this same patient died of sepsis 73 days later. Patient 4 had embolization and sclerotherapy and had no instance of rebleed 290 days after therapy. Patient 5 had TIPS procedure and was discharged five days post procedure without rebleed, patient has since been lost to follow-up.

Bleeding stomal varices in portal hypertension

We report a case of a 50-year-old man with a history of liver cirrhosis and colon cancer post end colostomy presenting to the emergency department with stomal bleeding and passage of clots into the colostomy bag. The patient was treated with transjugular intrahepatic portosystemic shunt (TIPS) and concomitant embolization of the stomal varices via the TIPS shunt using N-butyl cyanoacrylate mixed with ethiodol. Although stomal variceal bleeding is uncommon, this entity can have up to 40% mortality upon initial presentation, given the challenges in diagnosis and management. Currently, there are no established standard treatments for stomal variceal bleeding. In addition, to the best of our knowledge, there are no cases in the current literature in which treatment of this entity is performed with a combination of TIPS shunt placement and N-butyl cyanoacrylate variceal embolization.

Transjugular intrahepatic portosystemic shunt in the treatment of portal vein thrombosis: a critical review of literature

Reports of successful transjugular intrahepatic portosystemic shunt (TIPS) surgery in patients with portal vein thrombosis (PVT) are considered anecdotal owing to the technical difficulty of the procedure and potential procedure-related complications. A literature review was undertaken to determine the feasibility and safety of TIPS in the treatment of PVT. All studies in which TIPS was attempted in patients with PVT were identified by searching through the PUBMED and MEDLINE databases. A total of 424 PVT patients undergoing TIPS were reported in 54 articles. The success rate of TIPS insertion was 67-100% in 19 case series. Further, 85 patients with portal cavernoma underwent successful TIPS insertions. Three therapeutic strategies of TIPS placement were used: (1) TIPS placement followed by portal vein recanalization via the shunt, (2) portal vein recanalization via percutaneous approaches followed by TIPS placement, and (3) TIPS insertion between a hepatic vein and a large collateral vessel without portal vein recanalization. Four approaches were used to access the portal vein: transjugular, transhepatic, transsplenic, and transmesenteric. Intra-abdominal hemorrhage secondary to hepatic capsule perforation was lethal in only three patients. No episode of pulmonary embolism was reported. Other procedure-related complications were reversible. The overall incidence of shunt dysfunction and hepatic encephalopathy was 8-33% and 0-50%, respectively. In conclusion, the reviewed studies uniformly support the feasibility and safety of TIPS for PVT even in the presence of portal cavernoma. Further, several major issues that remain unresolved are discussed.

Clinicopathological features and treatment of ectopic varices with portal hypertension

Bleeding from ectopic varices, which is rare in patients with portal hypertension, is generally massive and life-threatening. Forty-three patients were hospitalized in our ward for gastrointestinal bleeding from ectopic varices. The frequency of ectopic varices was 43/1218 (3.5%) among portal hypertensive patients in our ward. The locations of the ectopic varices were rectal in thirty-two, duodenal in three, intestinal in two, vesical in three, stomal in one, and colonic in two patients. Endoscopic or interventional radiologic treatment was performed successfully for ectopic varices. Hemorrhage from ectopic varices should be kept in mind in patients with portal hypertension presenting with lower gastrointestinal bleeding.

A Case of Isolated Duodenal Varices Secondary to Chronic Pancreatitis with Review of Literature

An unusual case of upper gastrointestinal hemorrhage due to an isolated varix involving the 2nd part of the duodenum is presented here. The varix was the result of Chronic Pancreatitis induced the superior mesenteric vein obstruction. The diagnosis was made preoperatively by upper gastrointestinal endoscopy and selective mesenteric angiogram. Patient was treated successfully with Mesocaval shunt surgery between the superior mesenteric vein and the inferior vena cava using a 10 mm Dacron graft. This is the unique case showing hemorrhagic complication of Chronic Pancreatitis due to the superior mesenteric vein obstruction.

Direct percutaneous embolization of bleeding stomal varices

Stomal variceal bleeding can develop in patients with underlying cirrhosis and portal hypertension. Most patients are best treated with transjugular intrahepatic portosystemic shunt (TIPS) creation because this addresses the underlying problem of portal hypertension. However, some patients are not good candidates for TIPS creation because they have end-stage liver disease or encephalopathy. We describe such a patient who presented with recurrent bleeding stomal varices, which was successfully treated with percutaneous coil embolization. The patient had bleeding-free survival for 1 month before death from unrelated causes.

Updates in the pathogenesis, diagnosis and management of ectopic varices

Ectopic varices (EcV) comprise large portosystemic venous collaterals located anywhere other than the gastro-oesophageal region. No large series or randomized-controlled trials address this subject, and therefore its management is based on available expertise and facilities, and may require a multidisciplinary team approach. EcV are common findings during endoscopy in portal hypertensive patients and their bleeding accounts for only 1–5% of all variceal bleeding. EcV develop secondary to portal hypertension (PHT), surgical procedures, anomalies in venous outflow, or abdominal vascular thrombosis and may be familial in origin. Bleeding EcV may present with anaemia, shock, haematemesis, melaena or haematochezia and should be considered in patients with PHT and gastrointestinal bleeding or anaemia of obscure origin. EcV may be discovered during panendoscopy, enteroscopy, endoscopic ultrasound, wireless capsule endoscopy, diagnostic angiography, multislice helical computed tomography, magnetic resonance angiography, colour Doppler-flow imaging, laparotomy, laparoscopy and occasionally during autopsy. Patients with suspected EcV bleeding need immediate assessment, resuscitation, haemodynamic stabilization and referral to specialist centres. Management of EcV involves medical, endoscopic, interventional radiological and surgical modalities depending on patients’ condition, site of varices, available expertise and patients’ subsequent management plan.

Direct percutaneous approach for endoluminal glue embolization of stomal varices

The present report describes the authors' experience with direct endoluminal embolization for bleeding stomal varices. Between December 1998 and July 2006, seven patients with enterostomies, portal hypertension, and recurrent stomal variceal bleeding resistant to medical treatment were treated at a single institution. Ultrasonography was used to guide direct puncture of the varices. Direct endoluminal embolization with cyanoacrylate glue was performed under fluoroscopic control imaging. Embolization was successful in six of seven cases. One patient with hepatocellular carcinoma and complete portal thrombosis had three recurrences treated with the same technique, with clinical success. Three patients died at 3, 8, and 18 months without recurrence of bleeding. Although further evaluation is indicated, direct percutaneous embolization appears to be a potential alternative treatment for bleeding stomal varices.

Bleeding stomal varices: case series and systematic review of the literature

BACKGROUND & AIMS

Bleeding stomal varices are a common problem in patients with surgical stomas and portal hypertension, and remain difficult to diagnose and manage.

METHODS

We identified all patients at our institution with bleeding stomal varices from 1989 to 2004. We surveyed all patients undergoing ileal pouch-anal anastomosis from 1997 to 2007 for bleeding anastomotic varices. Finally, we performed a systematic review of the literature focusing on diagnosis and treatment of bleeding stomal varices that included 74 English language studies of 234 patients.

RESULTS

We identified 8 patients with bleeding stomal varices. Recognition of stomal varices typically was delayed, particularly when failing to examine the ostomy without the appliance. Stomal variceal bleeding was confirmed by Doppler ultrasound or angiographic imaging. Simple local therapy usually stopped bleeding, albeit temporarily. Sclerotherapy was effective, but at the expense of unacceptable stomal damage. Decompressive therapy was required for secondary prophylaxis, including transjugular intravascular transhepatic shunts (2 patients), surgical portosystemic shunts (2 patients), and liver transplantation (1 patient). No patient with an ileal pouch-anal anastomosis developed anastomotic bleeding from varices.

CONCLUSIONS

Primary prevention of bleeding stomal varices requires avoidance of creating enterocutaneous stomas in patients with portal hypertension. Careful inspection of the uncovered ostomy is essential for bleeding stomal varices diagnosis. Once identified, conservative measures will stop bleeding temporarily with definitive therapy required, including transjugular intravascular transhepatic shunts, surgical shunts, or liver transplantation.

A case of successful treatment of stomal variceal bleeding with transjugular intrahepatic portosystemic shunt and coil embolization

Variceal bleeding from enterostomy site is an unusual complication of portal hypertension. The bleeding, however, is often recurrent and may be fatal. The hemorrhage can be managed with local measures in most patients, but when these fail, surgical interventions or portosystemic shunt may be required. Herein, we report a case in which recurrent bleeding from stomal varices, developed after a colectomy for rectal cancer, was successfully treated by placement of transjugular intrahepatic portosystemic shunt (TIPS) with coil embolization. Although several treatment options are available for this entity, we consider that TIPS with coil embolization offers minimally invasive and definitive treatment.

Embolisation de varices stomiales par injection percutanée de colle biologique

In patients with cirrhosis and enterostomy, although bleeding stomal varices are rare, they can been severe and difficult to be treat. We report the first two cases of bleeding stomal varices treated by cyanoacrylate embolization, in patients with cirrhosis and colostomy. In each case, after pharmacological treatment of portal hypertension (propranolol) failed, embolization of the stomal varices by transdermal injection of biological glue effectively stopped the bleeding, without recurrence or side effects, after 8 and 16 months of follow-up. The embolization of stomal varices by biological glue is a safe, easy and efficient treatment for bleeding stomal varices.

Treatment of bleeding stomal varices by balloon-occluded retrograde transvenous obliteration

Although stomal varices are a rare complication, bleeding stomal varices often need to be treated owing to symptoms of hypovolemic shock, recurrence of stomal bleeding, or deterioration in the quality of life. Various treatment strategies for the management of bleeding stomal varices have thus far been reported. We report the case of a 60-year-old woman with refractory recurrent bleeding from varices in a sigmoid stoma, along with nonalcoholic steatohepatitis and marked splenomegaly. A physical examination revealed that the skin was discolored and bluish around the circumference of the sigmoid stoma. The venous phase of a celiac arteriogram revealed an afferent vein from the splenic vein and another from the inferior mesenteric vein, and veins draining into the left superficial epigastric vein. A balloon-occluded retrograde transvenous obliteration (BRTO) procedure was performed. The skin around the stoma, initially discolored bluish, improved markedly. After 10 months of follow-up, the patient has remained well without further episodes of stomal bleeding. To our knowledge, this is the first case of recurrent hemorrhage from stomal varices that was successfully treated by BRTO in a patient with portal hypertension.

Usefulness of transjugular intrahepatic portosystemic shunt in the management of bleeding ectopic varices in cirrhotic patients

PURPOSE

To evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the control of bleeding from ectopic varices.

METHODS

From 1995 to 2004, 24 cirrhotic patients, bleeding from ectopic varices, mean age 54.5 years (range 15-76 years), were treated by TIPS. The etiology of cirrhosis was alcoholic in 13 patients and nonalcoholic in 11 patients. The location of the varices was duodenal (n = 5), stomal (n = 8), ileocolic (n = 6), anorectal (n = 3), umbilical (n = 1), and peritoneal (n = 1).

RESULTS

TIPS controlled the bleeding in all patients and induced a decrease in the portacaval gradient from 19.7 +/- 5.4 to 6.4 +/- 3.1 mmHg. Postoperative complications included self-limited intra-abdominal bleeding (n = 2), self-limited hemobilia (n = 1), acute thrombosis of the shunt (n = 1), and bile leak treated by a covered stent (n = 1). Median follow-up was 592 days (range 28-2482 days). Rebleeding occurred in 6 patients. In 2 cases rebleeding was observed despite a post-TIPS portacaval gradient lower than 12 mmHg and was controlled by variceal embolization; 1 patient underwent surgical portacaval shunt and never rebled; in 3 patients rebleeding was related to TIPS stenosis and treated with shunt dilatation with addition of a new stent. The cumulative rate of rebleeding was 23% and 31% at 1 and 2 years, respectively. One- and 2-year survival rates were 80% and 76%, respectively.

CONCLUSION

The present series demonstrates that bleeding from ectopic varices, a challenging clinical problem, can be managed safely by TIPS placement with low rebleeding and good survival rates.

Transjugular intrahepatic porto-systemic shunt and variceal embolisation in the management of bleeding stomal varices

BACKGROUND AND AIMS

Bleeding from stomal varices is uncommon. Local measures to control the bleeding offer short-lived control. Our experience with transjugular intrahepatic porto-systemic shunt (TIPS) and variceal embolisation is presented and appraised.

PATIENT AND METHODS

Three patients presented with bleeding from stomal varices (Child-Pugh class B, n=2 and class C, n=1) in association with primary sclerosing cholangitis, autoimmune hepatitis and alcoholic liver disease. Local treatment measures including suture ligation, sclerotherapy and re-siting of the stoma achieved short-lived control. TIPS were inserted in all 3 patients, with embolisation of the stomal varices in 2.

RESULTS/FINDINGS

The radiological interventions were uncomplicated and resulted in cessation of the bleeding in all patients. One of the patients has had no further bleeding at 12 months' follow-up post-TIPS insertion. The other two patients re-bled at 5 and 6 months post-TIPS insertion and were successfully managed by insertion of a second TIPS in one patient and by balloon dilatation of the TIPS in another. The former patient has had no re-bleeding at a further 8 months' follow-up, while the latter had re-bleeding at 12 months post-TIPS insertion and underwent liver transplantation.

INTERPRETATION/CONCLUSION

Transjugular intrahepatic porto-systemic shunt with variceal embolisation offers an effective, minimally invasive management option in patients with bleeding stomal varices, and may be used as the primary mode of intervention in conjunction with medical therapy, and as the definitive therapy in patients unfit for surgery. TIPS and variceal embolisation do not preclude subsequent liver transplantation, and may be used during the acute situation as a bridge to transplantation.

Bleeding ectopic varices--treatment with transjugular intrahepatic porto-systemic shunt (TIPS) and embolisation

BACKGROUND/AIMS

Bleeding ectopic varices due to cirrhosis can be difficult to manage. We report our experience of uncontrolled bleeding from ectopic varices treated with transjugular intrahepatic porto-systemic shunt (TIPS).

METHODS

We selected the 21 cirrhotics who underwent TIPS for bleeding ectopic varices from our database: Child-Pugh grade A (2), B (11) and C (8). Site of bleeding was rectal (11), colonic (2), ileal 1, jejunal 1, duodenal 1, and stomal (5).

RESULTS

TIPS was performed successfully in 19/21 (90%) patients. All except 1 had either a reduction in portosystemic pressure gradient < or = 12 mmHg (n=12) or reduction by 25-50% of baseline (n=6). TIPS alone was used in 12/19: 7 of these 12 had no further bleeding; 5 (42%) rebled within 48 h, and had embolisation, 4 without further bleeding. In 7 of 19, TIPS and embolisation were performed together: 2 patients (28%) rebled; further embolisation stopped the bleeding.

CONCLUSIONS

Ectopic varices do rebleed despite a reduction of porto-systemic pressure gradient < or = 12 mmHg or by 25-50% of baseline, following TIPS. Embolisation stopped bleeding in all but 1 patient. We recommend performing embolisation at the time of the initial TIPS to control bleeding from ectopic varices.