Management of Parastomal Varices

Introduction: While varices arising at sites other than the gastroesophageal junction account for only 5% of variceal bleeding, bleeding stomal/parastomal varices (BSV) are relatively common in patients with portal hypertension and surgical stomas and can cause significant, possibly life-threatening, hemorrhage. Although most commonly occurring in the setting of portal hypertension, BSV can develop secondary to mesenteric thrombosis or postoperative changes from stoma creation itself. Local therapies can be effective at acute control, but diffuse or recurrent bleeding often requires more drastic measures. Depending on the classification and pathophysiology, treatment may involve surgical revision, transvenous obliteration, and/or transjugular intrahepatic portosystemic shunt (TIPS). However, data suggests a lower bleeding threshold than gastroesophageal varices with reported bleeding even with trans-sinusoidal pressure gradient below 12 mm Hg, and liver transplantation may be required. This exhibit will discuss the incidence, etiology, and classification of BSV, with proposed treatment algorithm and prognosis.

Content Organization:

1. Pathophysiology and anatomy of stomal varices.

2. Stomal varices classification system.

3. Various interventional radiology treatment options (i.e., balloon-occluded retrograde transvenous obliteration, balloon-occluded antegrade transvenous obliteration, direct ultrasound-guided sclerosis, decompression TIPS) and indications.

4. Institutional experience and case presentation

Learning Points: BSV is a relatively common entity in patients with surgical stomas and portal hypertension which can cause significant hemorrhage and present a challenging clinical scenario due to a low threshold for bleeding. Treatment depends on classification and mechanism behind the varices, and multidisciplinary involvement is key to determining optimal management.