A unique case of peristomal bleeding managed by BRTO in a patient with Spina bifida

Document Type

Conference Proceeding

Publication Date

10-1-2021

Publication Title

Am J Gastroenterol

Abstract

Introduction: Balloon-occluded retrograde transvenous obliteration (BRTO) is an endovascular technique commonly used in the management of gastric varices in which occlusion balloons are placed to modulate flow from the varices and a sclerosant is injected into the varices. BRTO can also be used as an alternative to transjugular intrahepatic portosystemic shunt (TIPS) for peristomal varices, especially in patients with significant liver disease or hepatic encephalopathy. We present an unusual case of a patient with spina bifida and cirrhosis with bleeding due to peristomal varices managed with BRTO. Case Description/Methods: A 36-year-old male with a past medical history significant for spina bifida, colocutaneous fistula with loop ileostomy, and cryptogenic cirrhosis presents with bright red blood from his ileostomy. He has previously been treated with silver nitrate at his ostomy site. Esophagogastroduodenoscopy shows moderate to severe portal hypertensive gastropathy with no evidence of recent bleeding and no gastric or esophageal varices seen. Ileoscopy shows normal ileum, but examination reveals peristomal varices. An explorative laparotomy is performed, and dense adhesions are visualized preventing ileostomy revision. Bleeding from the stoma persists and the patient undergoes BRTO targeting the peristomal varices. Transhepatic portal venous access, venogram, sclerosis and coil embolization of afferent portal vein to stoma and manometry are performed as well as coil and glue closure of the transhepatic tract. No peristomal rebleeding has occurred in 1 year since BRTO; however, the patient has developed ascites and is being monitored to check for esophageal varices development, in which case TIPS may need to be reconsidered. Discussion: Peristomal varices have a mortality rate around 3% to 4% and are estimated to occur in up to 27% of patients with ostomy concurrent with cirrhosis and portal hypertension. The most common treatment for peristomal varices is TIPS. TIPS addresses the underlying portal hypertension typically associated with peristomal varices, but has been widely shown to increase risk for hepatic encephalopathy. Given the patient's impaired baseline mental aptitude and preference to avoid treatment with osmotic laxative lactulose, TIPS was ruled out. Instead, BRTO was used as a localized treatment of the peristomal varices.

PubMed ID

Not assigned.

Volume

116

Issue

SUPPL

First Page

S999

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