Use of Non-Selective Beta-Blocker for Refractory Stomal Variceal Hemorrhage

Bleeding stomal varices are often difficult to manage given the comorbidities that are associated with their presentation. Here, we report a case of a 62-year-old female with stomal variceal hemorrhage in the setting of chronic portal vein thrombosis who was ineligible for transhepatic intrajugular portosystemic shunt or surgery as a result of her challenging anatomy and peri-operative risks. Despite coil embolization, this patient experienced refractory bleeds which ceased following the initiation of a non-selective beta-blocker (NSBB). This case provides further evidence for the expanding role of NSBBs as an important therapeutic agent for complicated ectopic varices.

Successful hybrid surgery for ileal conduit stomal varices following oxaliplatin-based chemotherapy in a patient with advanced colorectal cancer

Background Ectopic variceal bleeding is a rare but life-threatening complication of portal hypertension (PH). Oxaliplatin-based chemotherapy for colorectal cancer (CRC) is associated with sinusoidal obstruction syndrome of the liver, which can lead to PH. Case presentation Here, we report a successful hybrid surgery that included intraoperative obliteration of ileal conduit stomal varices (ICSVs) for a 66-year-old woman with CRC and liver metastasis that had been treated multimodally during the previous 4 years, including 17 courses of oxaliplatin-based chemotherapy. She was admitted to our hospital for massive hemorrhage from an ileal conduct stoma. Image findings showed ICSVs as a part of portosystemic shunt, which were afferently supplied from the superior mesenteric vein (SMV) and drained by the numerous cutaneous veins connected to the left femoral vein. Obliteration of the stomal varices by interventional radiologic techniques alone was inappropriate because of difficulties of cannulating the efferent cutaneous veins. We, therefore, performed hybrid surgery for the ICSV, which included cannulation into the SMV branch and antegrade obliteration of the varices with a 5% solution of ethanolamine oleate with iopamidol under blocking the SMV flow, using a vascular clip and ligation. Hemorrhage in her ileal conduit stoma disappeared completely. Conclusion Customized treatment of ectopic varices should be based on their precise vascular anatomy; hybrid surgery with intraoperative angiography is an alternative treatment for ectopic varices such as ICSV.

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

Ileostomy variceal bleeds can be a serious complication in patients with cirrhosis and ileostomy but make up a small portion of total variceal bleeds. Multiple modalities have been described as therapeutic options for stomal variceal bleeding, but an optimal intervention has yet to be established. We present a case of a 51-year-old patient with preserved ejection fraction heart failure, hepatitis C cirrhosis, recent esophageal varices banding, and colectomy with ileostomy who developed bleeding ileostomy varices that were effectively treated under direct ultrasound-guided percutaneous injection of sodium tetradecyl sulfate to the feeding superior mesenteric venous flow. The patient did not have a recurrence of bleeding at 7-month follow-up. We consider direct ultrasound-guided percutaneous injection of sodium tetradecyl sulfate of acute bleeding stomal varices to be safe and effective in decompensated cirrhotic patients.