Recurrent Bleeding From Ileal Conduit Stomal Varices in a Patient With Portal Hypertension
Article information
Abstract
Abstract
Bleeding from ileal conduit stomal varices is a rare complication. The standard treatment for the management of stomal varices has not been established yet. We present the case of a 65-year-old man with recurrent fatal bleeding from his ileal conduit stomal varices who was successfully treated with ligation of the engorged venous varices using hemostatic agents.
Bleeding from ileal conduit stomal varices is uncommon and rarely reported.1 It can particularly develop in portal hypertension patients, and fatal massive bleeding from stomal varices can occur,2 making early detection crucial. This bleeding mainly occurs in enterostomal varices at the mucocutaneous borderline level.3 Management is challenging and varies from local treatment to shunting, embolization, and surgery. We present the case of a 65-year-old man with recurrent fatal bleeding from his ileal conduit stomal varices successfully treated with ligation of the engorged venous varices using hemostatic agents.
Case Report
A 65-year-old man with massive ileal conduit stomal bleeding visited our Emergency Department. He underwent radical cystectomy with ileal conduit urinary diversion at another hospital in 2006. Three years previously, liver cirrhosis (severity of Child-Pugh score B) was diagnosed. However, he did not receive any treatment for liver cirrhosis. Five months previously, he first experienced stomal bleeding during abdominal straining or coughing. He only observed this situation because the bleeding was tolerable after self-compression, and 2 months previously, massive bleeding of about 800–1,000 mL per day occurred. He was admitted to the local hospital but only received transfusion of red blood cells and platelets.
At the Emergency Department, initial vital sign was stable but hemoglobin level was 7.7 g/dL and platelet count 88 K. Stomal bleeding emanated from the borderline at 6 o'clock between his ileal conduit and skin (Fig. 1). Transfusion was initiated, and abdominal computed tomography (CT) was performed. CT angiography showed parastomal cutaneous tortuous vessels connected to the mesenteric vessel, indicating a parastomal varix (Fig. 2). Radiologists were immediately consulted; however, angioembolization was not conducted because of difficulty in superselecting the bleeding venous varices and high risk of ileal conduit necrosis. Therefore, we performed operative ma-nagement. Under local anesthesia, we dissected the area between the ileal conduit and parastomal skin. The engorged vessel with active bleeding was identified and ligated using nonabsorbable suture with absorbable collagen hemostatic agents.
Stomal bleeding emanating from the borderline at 6 o'clock between the patient's ileal conduit and skin.
Abdominal computed tomography angiography showing the parastomal cutaneous tortuous vessels (arrow) connecting to the mesenteric vessel, indicating a parastomal varix.
Postoperatively, internal medicine doctors were consulted and liver cirrhosis management using ursodeoxycholic acid and diuretics was initiated. Follow-up duration was 18 months. Patient is free from stomal bleeding even when abdominal pressure rises.
This is a retrospective case report of single urology center. Present study was approved by the Institutional Review Board of Kyungpook National University, School of Medicine, Daegu, Republic of Korea (IRB No. KNUH 2020-05-009). This study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
Discussion
Ileal conduit stomal varices are rare. Studies on stomal varices are lacking, and most of these are case reports.4 Various conditions including calculi, infection, and cancer recurrence can cause ileal conduit bleeding5 and should be distinguished from ileal conduit stomal variceal bleeding. Stomal variceal bleeding can cause fatal massive blood loss; thus, prompt diagnosis and management are needed.
Typical varices, common liver cirrhosis compli-cations, mostly develop in the gastroesophageal area. Ectopic varices can occur in the entire gastrointestinal tract, including the ileal conduit stoma, accounting for approximately 5% of all variceal bleeding.1 High-pressure portal blood flow elevates variceal venous pressure of the stoma retrogradely; this elevated pressure is decompressed into a mucocutaneous venous network surrounding the stoma.6 Typical stomal bleeding on physical examination is observed in these mucocutaneous venous networks.
A standard treatment modality for stomal variceal bleeding is not established yet. A recent report recommended the consideration of various therapeutic approaches, including medical treatment, endoscopic management,7 intervention, surgical shunting, and liver transplantation.8 First, medical treatment for underlying portal hypertension should be performed. Conservative treatments, including local compression, bleeding vessel ligation, or sclerotherapy, may be considered but have a high recurrence rate of bleeding. In cases of continuous bleeding persisting even after initial treatment, endovascular embolization1,2,9 or transjugular intrahepatic portocaval shunt3,9,10 can be applied.
Urologists should be aware of the characteristics of ileal conduit stomal varices. Various thera-peutic approaches should be considered, and a fundamental treatment for the causative disease should be developed.
Notes
The authors claim no conflicts of interest.