TIPS for the management of stomal variceal bleeding due to cirrhotic and non-cirrhotic portal hypertension

Abstract

Background Portal hypertension (PH) is associated with the development of esophageal or gastric varices, which can cause bleedings with high mortality. Varices can also manifest at sites of stomata. These parastomal varices can cause recurrent variceal bleedings (VB) despite local therapies. We present a case series of parastomal VB due to PH that were managed with implantation of transjugular intrahepatic portosystemic shunt (TIPS).

Methods We retrospectively included all patients (pt) from 2 tertiary medical centers with parastomal VB between January 2014 and February 2020 who underwent the TIPS procedure.

Results Nine pt were included. Seven pt had liver cirrhosis, mostly alcohol-related. Two pt had non-cirrhotic PH due to porto-sinusoidal vascular disease (PSD). Four pt had a colostomy, 1 an ileostomy, and 4 an ileal conduit. Malignancy was the leading cause of stoma surgery. All 9 pt suffered from recurrent parastomal VB despite non-selective beta-blocker and/or local therapy (e.g., compression, coagulation, suture ligation, or surgical stoma revision). All pt received TIPS implantation. In 7 pt, TIPS implantation led to sustainable hemostasis. Two pt suffered a bleeding relapse that was attributable to TIPS dysfunction. TIPS revision with coil embolization of the varices terminated the VB sustainably in both pt.

Conclusions In pt presenting with recurrent stomal bleedings, parastomal varices as a rare complication of PH must be taken into consideration as an underlying cause. In our case series, we managed to sustainably cease parastomal VB by TIPS implantation with or without coil embolization of the ectopic varices.

Zusammenfassung

Hintergrund Portale Hypertension (PH) ist mit der Ausbildung von Ösophagus- und Magenvarizen verbunden, die lebensbedrohliche Blutungen verursachen können. Varizen können sich auch im Bereich von Stomata manifestieren. Diese parastomalen Varizen können trotz lokaler Therapiemaßnahmen zu rezidivierenden Varizenblutungen (VB) führen. Wir berichten über eine Fallserie parastomaler VB aufgrund PH, die mittels Implantation eines transjugulären intrahepatischen portosystemischen Shunts (TIPS) behoben wurden.

Methoden Wir schlossen retrospektiv alle Patienten (Pt) zweier Krankenhäuser der Maximalversorgung ein, die sich zwischen Januar 2014 und Februar 2020 mit parastomalen VB vorgestellt hatten und eine TIPS-Implantation erhielten.

Ergebnisse Neun Pt wurden eingeschlossen. Sieben Pt hatten eine Leberzirrhose, überwiegend alkoholbedingt. Zwei Pt hatten eine nicht-zirrhotische PH wegen porto-sinusoidaler vaskulärer Erkrankung (PSD). Vier Pt hatten ein Kolostoma, 1 ein Ileostoma und 4 ein Ileumkonduit. Eine maligne Grunderkrankung war die häufigste Ursache für die vorausgegangene Stomaversorgung. Alle 9 Pt litten an rezidivierenden VB trotz nichtselektiver Betablockade und/oder Lokaltherapie wie Kompression, Koagulation, Übernähung oder operative Stomarevision. Alle Pt erhielten eine TIPS-Implantation. Bei 7 Pt führte die TIPS-Implantation zu einer nachhaltigen Hämostase. Zwei Pt erlitten ein VB-Rezidiv, das kausal auf eine TIPS-Dysfunktion zurückgeführt werden konnte. Eine TIPS-Revision mit Coil-Embolisation der Varizen beendete die Blutung jeweils nachhaltig.

Schlussfolgerungen Bei Pt, die sich mit rezidivierenden Stomablutungen vorstellen, müssen parastomale Varizen als seltene Komplikation der PH als mögliche zugrunde liegende Blutungsursache in Betracht gezogen werden. In unserer Fallserie gelang es uns, parastomale VB nachhaltig durch eine TIPS-Implantation mit und ohne Coil-Embolisation zu stillen.

Schlüsselwörter

Zirrhose - Leber - portale Hypertonie - transjugulärer intrahepatischer portosystemischer Shunt - Varizenblutung

Keywords

cirrhosis - liver - portal hypertension - transjugular intrahepatic portosystemic shunt - variceal bleeding

Publication History

Received: 22 January 2021

Accepted after revision: 09 May 2021

Article published online:
05 November 2021

• References

• 1 Berzigotti A, Seijo S, Reverter E. et al. Assessing portal hypertension in liver diseases. Expert Rev Gastroenterol Hepatol 2013; 7: 141-155 DOI: 10.1586/egh.12.83. (PMID: 23363263)
• 2 Asrani SK, Larson JJ, Yawn B. et al. Underestimation of liver-related mortality in the United States. Gastroenterology 2013; 145: 375-382.e2 DOI: 10.1053/j.gastro.2013.04.005. (PMID: 23583430)
• 3 Praktiknjo M, Simón-Talero M, Römer J. et al. Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis. J Hepatol 2020; 72: 1140-1150 DOI: 10.1016/j.jhep.2019.12.021. (PMID: 31954206)
• 4 Simón-Talero M, Roccarina D, Martínez J. et al. Association Between portosystemic shunts and increased complications and mortality in patients with cirrhosis. Gastroenterology 2018; 154: 1694-1705.e4 DOI: 10.1053/j.gastro.2018.01.028. (PMID: 29360462)
• 5 De Gottardi A, Rautou P-E, Schouten J. et al. Porto-sinusoidal vascular disease: proposal and description of a novel entity. Lancet Gastroenterol Hepatol 2019; 4: 399-411 DOI: 10.1016/S2468-1253(19)30047-0. (PMID: 30957754)
• 6 Darwish Murad S, Plessier A, Hernandez-Guerra M. et al. Etiology, management, and outcome of the Budd-Chiari syndrome. Ann Intern Med 2009; 151: 167-175 DOI: 10.7326/0003-4819-151-3-200908040-00004. (PMID: 19652186)
• 7 European Association for the Study of the Liver. Electronic address: [e-mail]. EASL Clinical Practice Guidelines: vascular diseases of the liver. J Hepatol 2016; 64: 179-202 DOI: 10.1016/j.jhep.2015.07.040.
• 8 de Franchis R, Baveno VI Faculty. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752 DOI: 10.1016/j.jhep.2015.05.022. (PMID: 26047908)
• 9 Maruyama H, Yokosuka O. Pathophysiology of Portal hypertension and esophageal varices. Int J Hepatol 2012; 2012 DOI: 10.1155/2012/895787. (PMID: 22666604)
• 10 Triantafyllou M, Stanley AJ. Update on gastric varices. World J Gastrointest Endosc 2014; 6: 168-175 DOI: 10.4253/wjge.v6.i5.168. (PMID: 24891929)
• 11 Sarin SK, Agarwal SR. Gastric varices and portal hypertensive gastropathy. Clin Liver Dis 2001; 5: 727-767 DOI: 10.1016/S1089-3261(05)70190-2. (PMID: 11565139)
• 12 Pennick MO, Artioukh DY. Management of parastomal varices: who re-bleeds and who does not? A systematic review of the literature. Tech Coloproctol 2013; 17: 163-170 DOI: 10.1007/s10151-012-0922-6.
• 13 Kochar N, Tripathi D, McAvoy NC. et al. Bleeding ectopic varices in cirrhosis: the role of transjugular intrahepatic portosystemic stent shunts. Aliment Pharmacol Ther 2008; 28: 294-303 DOI: 10.1111/j.1365-2036.2008.03719.x. (PMID: 19086235)
• 14 Lashley DB, Saxon RR, Fuchs EF. et al. Bleeding ileal conduit stomal varices: diagnosis and management using transjugular transhepatic angiography and embolization. Urology 1997; 50: 612-614 DOI: 10.1016/S0090-4295(97)00267-7. (PMID: 9338744)
• 15 Spier BJ, Fayyad AA, Lucey MR. et al. Bleeding stomal varices: case series and systematic review of the literature. Clin Gastroenterol Hepatol 2008; 6: 346-352 DOI: 10.1016/j.cgh.2007.12.047. (PMID: 18328439)
• 16 Carrafiello G, Laganà D, Giorgianni A. et al. Bleeding from peristomal varices in a cirrhotic patient with ileal conduit: treatment with transjugular intrahepatic portocaval shunt (TIPS). Emerg Radiol 2007; 13: 341-343 DOI: 10.1007/s10140-006-0564-y.
• 17 Lee S-M, Yogan K, Carr T. Stomal varices: a cause for intermittent haematuria post-radical cystectomy. BMJ Case Rep 2016; 2016 DOI: 10.1136/bcr-2015-214082. (PMID: 26762355)
• 18 Noubibou M, Douala HC, Druez PM. et al. Chronic stomal variceal bleeding after colonic surgery in patients with portal hypertension: efficacy of beta-blocking agents?. Eur J Gastroenterol Hepatol 2006; 18: 807-808 DOI: 10.1097/01.meg.0000224480.74298.0a. (PMID: 16772844)
• 19 Scaletscky R, Wright JK, Shaw J. et al. Ileal conduit venous varices from portal hypertension as a cause of recurrent, massive hemorrhage: case report and review of the literature. J Urol 1994; 151: 417-419 DOI: 10.1016/s0022-5347(17)34967-4. (PMID: 8283541)
• 20 Takano M, Imai Y, Nakazawa M. et al. A case of liver cirrhosis with bleeding from stomal varices successfully treated using balloon-occluded retrograde transvenous obliteration. Clin J Gastroenterol 2016; 9: 145-149 DOI: 10.1007/s12328-016-0644-9. (PMID: 27048279)
• 21 Tomizawa Y, Sakuraba A, Pekow J. Parastomal variceal bleeding attributed to obstructive pathology successfully treated by percutaneous variceal embolization. ACG Case Rep J 2014; 1: 217-219 DOI: 10.14309/crj.2014.58. (PMID: 26157881)
• 22 Valaydon Z, Desmond P. Treatment of refractory stomal variceal haemorrhage with embolisation and sclerosis. Intern Med J 2015; 45: 214-217 DOI: 10.1111/imj.12662. (PMID: 25650536)
• 23 Vangeli M, Patch D, Terreni N. et al. Bleeding ectopic varices--treatment with transjugular intrahepatic porto-systemic shunt (TIPS) and embolisation. J Hepatol 2004; 41: 560-566 DOI: 10.1016/j.jhep.2004.06.024. (PMID: 15464235)
• 24 Wang L, Zhou J, Yang N. et al. Ectopic variceal bleeding from colonic stoma: two case reports. Medicine (Baltimore) 2015; 94: e406 DOI: 10.1097/MD.0000000000000406. (PMID: 25590847)
• 25 Wang MM, McGrew W, Dunn GD. Variceal bleeding from an ileostomy stoma. South Med J 1985; 78: 733-737 DOI: 10.1097/00007611-198506000-00029. (PMID: 4002005)
• 26 Wong RC, Berg CL. Portal hypertensive stomapathy: a newly described entity and its successful treatment by placement of a transjugular intrahepatic portosystemic shunt. Am J Gastroenterol 1997; 92: 1056-1057 (PMID: 9177535)
• 27 Conte JV, Arcomano TA, Naficy MA. et al. Treatment of bleeding stomal varices. Report of a case and review of the literature. Dis Colon Rectum 1990; 33: 308-314 DOI: 10.1007/BF02055474. (PMID: 2182311)
• 28 Hesterberg R, Stahlknecht CD, Röher HD. Sclerotherapy for massive enterostomy bleeding resulting from portal hypertension. Dis Colon Rectum 1986; 29: 275-277 DOI: 10.1007/BF02553038. (PMID: 3485037)
• 29 Thomas DJ, Abercrombie GF. Peri-stomal varices: an unusual cause of bleeding from an ileal conduit. Br J Urol 1993; 71: 355-356 DOI: 10.1111/j.1464-410x.1993.tb15960.x. (PMID: 8477324)
• 30 Crooks KK, Hensle TW, Heney NM. et al. Ileal conduit hemorrhage secondary to portal hypertension. Urology 1978; 12: 689-693 DOI: 10.1016/0090-4295(78)90433-8. (PMID: 311099)
• 31 Götz M, Anders M, Biecker E. et al. S2k Guideline Gastrointestinal Bleeding – Guideline of the German Society of Gastroenterology DGVS. Z Gastroenterol 2017; 55: 883-936 DOI: 10.1055/s-0043-116856. (PMID: 29186643)
• 32 Beck DE, Fazio VW, Grundfest-Broniatowski S. Surgical management of bleeding stomal varices. Dis Colon Rectum 1988; 31: 343-346 DOI: 10.1007/bf02564880. (PMID: 3366031)
• 33 Bilkhu A, Saha A, Ilsley DW. Topical use of tranexamic acid to control parastomal bleeding. Ann R Coll Surg Engl 2015; 97: 159 DOI: 10.1308/rcsann.2015.97.2.159b. (PMID: 25723699)
• 34 Kishimoto K, Hara A, Arita T. et al. Stomal varices: treatment by percutaneous transhepatic coil embolization. Cardiovasc Intervent Radiol 1999; 22: 523-525 DOI: 10.1007/s002709900445. (PMID: 10556416)
• 35 Minami S, Okada K, Matsuo M. et al. Treatment of bleeding stomal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol 2007; 42: 91-95 DOI: 10.1007/s00535-006-1960-5. (PMID: 17323000)
• 36 Onishi Y, Kimura H, Kanagaki M. et al. Successful embolization of ileal conduit stomal varices with N-butyl cyanoacrylate via a recanalized paraumbilical vein. Radiol Case Rep 2018; 13: 1130-1132 DOI: 10.1016/j.radcr.2018.07.024. (PMID: 30233743)
• 37 Saad WE, Saad NE, Koizumi J. Stomal varices: management with decompression tips and transvenous obliteration or sclerosis. Tech Vasc Interv Radiol 2013; 16: 176-184 DOI: 10.1053/j.tvir.2013.02.005. (PMID: 23830674)
• 38 Grundfest-Broniatowski S, Fazio V. Conservative treatment of bleeding stomal varices. Arch Surg 1983; 118: 981-985 DOI: 10.1001/archsurg.1983.01390080083021. (PMID: 6603209)
• 39 Samaraweera RN, Feldman L, Widrich WC. et al. Stomal varices: percutaneous transhepatic embolization. Radiology 1989; 170: 779-782 DOI: 10.1148/radiology.170.3.2783784. (PMID: 2783784)
• 40 Roberts PL, Martin FM, Schoetz DJ. et al. Bleeding stomal varices. The role of local treatment. Dis Colon Rectum 1990; 33: 547-549 DOI: 10.1007/BF02052204. (PMID: 2361420)
• 41 García-Pagán JC, Caca K, Bureau C. et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362: 2370-2379 DOI: 10.1056/NEJMoa0910102. (PMID: 20573925)
• 42 Hernández-Gea V, Procopet B, Giráldez Á. et al. Preemptive-TIPS Improves outcome in high-risk variceal bleeding: an observational study. Hepatology 2019; 69: 282-293 DOI: 10.1002/hep.30182. (PMID: 30014519)
• 43 Angeli P, Bernardi M, Villanueva C. et al. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; DOI: 10.1016/j.jhep.2018.03.024.
• 44 Alkari B, Shaath NM, El-Dhuwaib Y. et al. Transjugular intrahepatic porto-systemic shunt and variceal embolisation in the management of bleeding stomal varices. Int J Colorectal Dis 2005; 20: 457-462 DOI: 10.1007/s00384-004-0669-2. (PMID: 15650829)
• 45 Nayar M, Saravanan R, Rowlands PC. et al. TIPSS in the treatment of ectopic variceal bleeding. Hepatogastroenterology 2006; 53: 584-587 (PMID: 16995467)
• 46 Oey RC, de Wit K, Moelker A. et al. Variable efficacy of TIPSS in the management of ectopic variceal bleeding: a multicentre retrospective study. Aliment Pharmacol Ther 2018; 48: 975-983 DOI: 10.1111/apt.14947. (PMID: 30136292)
• 47 Trebicka J, Bastgen D, Byrtus J. et al. Smaller-Diameter covered transjugular intrahepatic portosystemic shunt stents are associated with increased survival. Clin Gastroenterol Hepatol 2019; DOI: 10.1016/j.cgh.2019.03.042.
• 48 Praktiknjo M, Lehmann J, Nielsen MJ. et al. Acute decompensation boosts hepatic collagen type III deposition and deteriorates experimental and human cirrhosis. Hepatol Commun 2018; 2: 211-222 DOI: 10.1002/hep4.1135. (PMID: 29404528)
• 49 Praktiknjo M, Clees C, Pigliacelli A. et al. Sarcopenia is associated with development of acute-on-chronic liver failure in decompensated liver cirrhosis receiving transjugular intrahepatic portosystemic shunt. Clin Transl Gastroenterol 2019; 10: e00025 DOI: 10.14309/ctg.0000000000000025. (PMID: 30939488)
• 50 Praktiknjo M, Book M, Luetkens J. et al. Fat-free muscle mass in magnetic resonance imaging predicts acute-on-chronic liver failure and survival in decompensated cirrhosis. Hepatology 2018; 67: 1014-1026 DOI: 10.1002/hep.29602. (PMID: 29059469)
• 51 Rössle M, Maruschke L, Radecke K. et al. Usefulness of a balloon-expandable, covered stent for the transjugular intrahepatic portosystemic shunt. J Radiol Imaging 2018; 3: 1-5 DOI: 10.14312/2399-8172.2018-1.
• 52 Sauerbruch T, Mengel M, Dollinger M. et al. Prevention of rebleeding from esophageal varices in patients with cirrhosis receiving small-diameter stents versus hemodynamically controlled medical therapy. Gastroenterology 2015; 149: 660-668.e1 DOI: 10.1053/j.gastro.2015.05.011. (PMID: 25989386)
• 53 Holster IL, Tjwa ETTL, Moelker A. et al. Covered transjugular intrahepatic portosystemic shunt versus endoscopic therapy + β-blocker for prevention of variceal rebleeding. Hepatology 2016; 63: 581-589 DOI: 10.1002/hep.28318.
• 54 Rudler M, Cluzel P, Corvec TL. et al. Early-TIPSS placement prevents rebleeding in high-risk patients with variceal bleeding, without improving survival. Aliment Pharmacol Ther 2014; 40: 1074-1080 DOI: 10.1111/apt.12934. (PMID: 25230051)
• 55 Trebicka J, Gluud LL. Reply to: “Adding embolization to TIPS implantation: A better therapy to control bleeding from ectopic varices?”. J Hepatol 2017; 67: 202-203 DOI: 10.1016/j.jhep.2017.03.018. (PMID: 28347803)
• 56 Trebicka J. Emergency TIPS in a Child-Pugh B patient: when does the window of opportunity open and close?. J Hepatol 2017; 66: 442-450 DOI: 10.1016/j.jhep.2016.10.025. (PMID: 27984174)