0016-5107/90/3605-0472$02.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1990 by the American Society for Gastrointestinal Endoscopy

The role of endoscopic injection sclerotherapy in the management of bleeding peristomal varices H. c. Wolfsen, MD, R. A. Kozarek, MD

J. E. Bredfeldt, MD, L. F. Fenster, MD, L. L. Brubacher, ARNP Seattle, Washington

Peristomal varices usually occur in patients with enterostomies who develop portal hypertension, and represent a cause of recurrent or intractable gastrointestinal bleeding. Treatment options for such bleeding include surgical ligation of varices, stoma revision with devascularization, injection sclerotherapy, portacaval shunt, or liver transplantation. We reviewed the records of seven patients with peristomal varices, who were followed for a mean of 17 months after diagnosis. Fourteen episodes of clinically significant peristomal bleeding occurred in six patients. Surgical ligation of varices was ineffective in controlling bleeding in two of three patients, although stoma revision with devascularization was temporarily effective in two other patients. Injection sclerotherapy, used in three patients, effectively controlled acute bleeding without serious complications or need for surgery. Definitive treatment for peristomal bleeding (portacaval shunt or liver transplantation) has prevented any further bleeding in three patients for a mean of 8 months after surgery. (Gastrointest Endosc 1990;36:472-474)

Peristomal varices have been noted in approximately one half of patients with enterostomies who subsequently develop portal hypertension. Moreover, episodes of serious bleeding have been reported in up to 100% of such patients. 1 Historically, surgical techniques have been employed in the treatment of peristomal variceal bleeding. 2 Injection sclerotherapy has also been used with variable results in the five patients reported to date. 3- s We report here our experience with seven patients diagnosed with peristomal varices, with clinically significant variceal bleeding occurring in six patients, three of whom were managed successfully with injection sclerotherapy. MATERIALS AND METHODS

Since 1983, seven patients have been diagnosed with peristomal varices at our institution. Medical records were reviewed for indications for stoma surgery, etiology of portal Received January 25, 1990. For revision April 1, 1990. Accepted June 6,1990. From the Section of Gastroenterology, Virginia Mason Clinic, Seattle, Washington, Reprint requests: R. A. Kozarek, MD, Section of Gastroenterology, Virginia Mason Clinic, 1100 Ninth Street, P.O. Box 900, Seattle, Washington 98111.


hypertension, episodes of peristomal bleeding, and its treatment and course. Clinically, significant bleeding from peristomal varices was defined as bleeding requiring medical or surgical evaluation and treatment, with or without blood transfusions. Methods of treatment included blood transfusions plus local pressure and silver nitrate cautery, surgical variceal ligation, stoma revision with devascularization, injection sclerotherapy, portacaval shunt, or liver transplantation. Sclerotherapy was done with fluoroscopic guidance into terminal ileal and stomal varices. After a test injection of contrast medium alone, 3.0% sodium tetradecyl sulfate sclerosant with an equal volume of 60% Conray"" contrast medium was injected in 0.5-ml increments. Fluoroscopy was used to ensure that sclerosant was injected into large ileal and peristomal varices and that no sclerosing agent reached the portal vein, thereby risking portal vein thrombosis. Sclerotherapy injections were performed endoscopically for ileal varices with additional free-hand injections of varices at the stoma mucocutaneous junction. No injections were made into parastomal skin. Indications for original ileostomy surgery were chronic ulcerative colitis (five patients) and Crohn's disease (1 patient). One patient had undergone urostomy placement for bladder exstrophy. Portal hypertension developed on the basis of chronic active hepatitis in three patients, sclerosing GASTROINTESTINAL ENDOSCOPY

cholangitis in two patients, alcoholic cirrhosis in one patient, and cryptogenic cirrhosis in one patient.


Peristomal varices were diagnosed in seven patients at a mean of 139 months after stoma surgery (range, 19 to 294 months). Six patients had the diagnosis made at the time of presentation with peristomal bleeding whereas the other patient was diagnosed at the time of evaluation for chronic peristomal ulcers. These patients were followed for a mean of 17 months after peristomal varices were diagnosed (range, 1 to 67 months). Fourteen episodes of clinically significant bleeding from peristomal varices occurred in six patients (Figs. 1 and 2). Three patients had stomal varices alone, and bleeding was treated with silver nitrate cautery and local pressure in one patient, and stoma revision surgery in two other patients. Stoma revision with devascularization controlled acute bleeding for 7 and 11 months, respectively. Subsequent rebleeding was treated with multiple transfusions plus cautery in the former patient and portacaval shunt in the latter. Surgical variceal ligation, performed as initial therapy at other institutions in three additional patients, controlled acute bleeding in only one of four treatments, prompting transfer of these patients to our facility. Bleeding distal ileal as well as peristomal varices were found in all three patients and were treated with endoscopic injection sclerotherapy. Silver nitrate cautery and local pressure were used to reduce oozing of blood from external injection sites. The latter three patients suffered a total of 10 bleeding episodes, all of which required blood transfusions (mean, 4.4 units/episode, range, 2 to 16 units). The first patient had three bleeds. One was controlled with sclerotherapy after failed variceal ligation, one with massive transfusions and extensive silver nitrate cautery of stomal varices following a second failed ligation 3 months later, and a terminal bleed resulted in exsanguination prior to intervention. The second patient had a single occurrence of bleeding which was controlled with sclerotherapy after failed variceal ligation. This patient underwent elective liver transplantation 5 months later. The third patient had six bleeding episodes, of which three were controlled with transfusions plus local stomal measures, including silver nitrate cautery. These bleeding episodes resolved after mesocaval shunt surgery. Three bleeding episodes occurred subsequently after shunt thrombosis 7 months later. Each of these bleeds were controlled with sclerotherapy, permitting liver transplantation 20 months after shunt thrombosis. In these patients a mean of two treatments per course of sclerotherapy were utilized (range, 1 to 4), with a mean total volume of 12 ml of sclerosant being VOLUME 36, NO.5, 1990

Figure 1. Gross appearance of peristomal varices. Figure 2. Endoscopic view of massive ileal varices.

used per injection course (range, 5 to 18.5 ml). Sclerotherapy was effective in controlling acute bleeding from peristomal varices in each case and oozing of blood from injection sites was treated with local pressure and silver nitrate cautery. Complications were limited to a single I-em ulcer which developed at an injection site in one patient and healed spontaneously within 2 weeks. Sclerotherapy prevented subsequent rebleeding for a mean of 6 months (range, 3 to 9 months). DISCUSSION

Peristomal varices have been reported to occur in more than 50% of patients with enterostomies who subsequently develop portal hypertension. 1 Episodes of serious bleeding from peristomal varices have been noted in up to 100% of such patients with an estimated mortality of 3 to 4% per bleeding episode. 1 •2 Treatment 473

options for peristomal variceal bleeding have traditionally been surgical, including ligation of varices, stoma revision with or without devascularization, or portacaval shunt. 3 Ligation of varices is often used as initial therapy but does not control acute bleeding reliably and has been associated with a high rate of rebleeding. 6 - 9 Stoma revision with devascularization has reportedly been effective in controlling acute bleeding,lO,l1 This method requires laparotomy, is associated with the development of new varices around the revised stoma site, and has not been shown to prevent recurrence of peristomal variceal bleeding. 11, 12 Portacaval shunt surgery is advocated by some authors as the procedure of choice for peristomal variceal hemorrhage. 2,6,12 The utility of this surgery is limited, however, by significant operative morbidity and mortality, post-operative encephalopathy, and the increased operative mortality with non-mesocaval shunt procedures if subsequent liver transplantation surgery is required. 9 ,l0,13-16 Recently, interest has been focused on the somewhat controversial use of sclerotherapy for the management of acute bleeding from peristomal varices. 11 Peck and Boyden lO cite a personal communication of two cases associated with disastrous skin necrosis. A further review of the literature reveals five additional case reports using sclerotherapy for such bleeding. 3- 5 Results from this limited experience are encouraging since this technique was successful in controlling acute peristomal variceal bleeding in all five cases. Moreover, sclerotherapy prevented rebleeding for more than 6 months in one of the patients. Complications were limited to a solitary post-injection ulcer in one patient that completely healed in 8 weeks. 5 Our results with the use of injection sclerotherapy for peristomal bleeding in three patients likewise indicate that this technique not only is effective in the management of acute bleeding episodes but can prevent recurrent bleeding for up to 9 months. In our hands, sclerotherapy was safe. No serious complications were noted when sclerotherapy was performed using fluoroscopic guidance, although special caution was taken to avoid peristomal skin injections since these are known to cause skin necrosis and subsequent ostomy appliance dysfunction. Injection sclerotherapy retains important advantages over surgical treatment modalities for peristomal variceal bleeding in that it


avoids the need for laparotomy and stoma revision while permitting subsequent definitive portal venous decompression procedures (portacaval shunt or liver transplantation) to be done on an elective basis. Thus, while limited information is available regarding treatment of peristomal varices, our results suggest that injection sclerotherapy merits consideration as a safe and effective treatment modality for acute management of bleeding from peristomal varices.

REFERENCES 1. Wiesner RH, LaRusso NF, Dozois RR, et al. Peristomal varices after proctocolectomy in patients with primary sclerosing cholangitis. Gastroenterology 1986;90:316-22. 2. Ricci RL, Lee KR, Greenberger NJ. Chronic gastrointestinal bleeding from ileal varices after total proctocolectomy for ulcerative colitis: correction by mesocaval shunt. Gastroenterology 1980;78:1053-8. 3. Finemore RG. Repeated haemorrhage from a terminal colostomy due to mucocutaneous varices with coexisting hepatic metastatic rectal adenocarcinoma: a case report. Br J Surg 1979;66:806. 4. Hesterberg R, Stahlknecht CD, Roher HD. Sclerotherapy for massive enterostomy bleeding resulting from portal hypertension. Dis Colon Rectum 1986;29:275-7. 5. Morgan TR, Feldshon SD, Tripp MR. Recurrent stomal variceal bleeding. Dis Colon Rectum 1986;29:269-70. 6. Ackerman NB, Graeber GM, Fey J. Enterostomal varices secondary to portal hypertension. Arch Surg 1980;115:1454-5. 7. Graeber GM, Ratner MH, Ackerman NB. Massive hemorrhage from ileostomy and colostomy stomas due to mucocutaneous varices in patients with coexisting cirrhosis. Surgery 1976;79:107-10. 8. Crooks K, Hensle TW, Heney NM, et al. Ileal conduit hemorrhage secondary to portal hypertension. Urology 1978;12:68993. 9. Grundfest-Broniatowski S, Fazio V. Conservative treatment of bleeding stomal varices. Arch Surg 1983;118:981-5. 10. Peck JJ, Boyden AM. Exigent ileostomy hemorrhage: a complication of proctocolectomy in patients with chronic ulcerative colitis and primary sclerosing cholangitis. Am J Surg 1985;150:153-6. 11. Beck DE, Fazio V, Grundfest-Broniatowski S. Surgical management of bleeding stomal varices. Dis Colon Rectum 1988;31:343-6. 12. Goldstein MB, Brandt LJ, Bernstein LH, et al. Hemorrhage from ileal varices: a delayed complication after total proctocolectomy in a patient with ulcerative colitis and cirrhosis. Am J GastroenteroI1983;78:351-4. 13. Samaraweera RN, Feldman L, Widrich WC, et al. Stomal varices: percutaneous transhepatic embolization. Radiology 1989;170:779-82. 14. Adson MA, Fulton RE. The ileal stoma and portal hypertension: an uncommon site of variceal bleeding. Arch Surg 1977;112:5013. 15. Wang MMJ, McGrew W, Dunn GD. Variceal bleeding from an ileostomy stoma. South Med J 1985;78:733-7. 16. Starzl TE, Iwatsuki S, Van Thiel DH, et al. Evolution of liver transplantation. Hepatology 1982;2:614-36.


The role of endoscopic injection sclerotherapy in the management of bleeding peristomal varices.

Peristomal varices usually occur in patients with enterostomies who develop portal hypertension, and represent a cause of recurrent or intractable gas...
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