Treatment of Bleeding Stomal Varices Report
of a Case
and
Review
of the Literature
J O H N V. CONTE, M . D . , T O D D A. ARCOMANO, M . D . , MOHAMMED A. NAFICY, M . D . , RICHARD W. H O L T , M . D .
Conte JV, Arcomano TA, Naficy MA, Holt RW. Treatment of bleeding stomal varices: report of a case and review of the literature. Dis Colon Rectum 1990;33:308-314. Variceal bleeding from ileostomy, colostomy, or ileal conduit stomas is unusual. There is no consensus on which of the various treatment options is best. A case of bleeding ileostomy varices is presented. The English-language medical literature since 1962 is reviewed and an additional 71 cases of stomal variceal bleeding are identified. Treatment options evaluated include stomal manipulation, variceal ligation, sclerotherapy, beta blockade, and surgical shunting. The incidence of rebleeding, requirement for additional procedures, and survival with the various options are compared. Although stomal manipulation was the most commonly performed procedure, portosystemic shunting had the lowest incidence of both rebleeding and need for additional procedures (4 percent each) and provided the longest mean postoperative survival (50 months). The authors conclude that portosystemic shunting is the treatment of choice in patients with bleeding from stomal varices who are good surgical candidates. [Key words: Portal hypertension; Stomal varices; Portocaval shunt] VARICEAL BLEEDING f r o m c o l o s t o m y , i l e o s t o m y , o r ileal c o n d u i t s t o m a s is a n u n u s u a l c o m p l i c a t i o n of p o r t a l hypertension. T h e b l e e d i n g o r i g i n a t e s f r o m e n t e r o s t o m a l varices located at the level of the m u c o c u t a n e o u s b o r d e r of the stoma. T h e s e variees are the result of a n a s t a m o s e s b e t w e e n the h i g h - p r e s s u r e p o r t a l v e n o u s system a n d the l o w pressure systemic v e n o u s system a r o u n d the stoma. 1-4
9Address reprint requests to Dr. Holt: Department of Surgery, Georgetown University Medical Center, 3800 Reservoir Rd., N.W., Washington, D.C. 20007.
308
From the Department of Surgery, Georgetown University Medical Center, and Georgetown University Surgical Division, District of Columbia General Hospital Washington, District of Columbia
Bleeding can arise spontaneously as a result of erosion of a submucosal varix or from local trauma. Treatment options include portosystemic shunting? -9 stomal revisions or disconnections,2,1~ ix bowel resection, 4 ligation of individual varices,9,12-14 sclerotherapy?, 15 beta blockade, TM and direct local pressure. A l t h o u g h there are m a n y treatment modalities available, no consensus exists on which treatment is best. In this article, a case of bleeding ileostomy varices is reported and a review of the English-language medical literature since 1962 to assess the efficacy of the various treatment options. Report of a Case A 35-year-old black woman presented in the emergency room of the hospital with her eighth documented episode of bleeding from an ileostomy stoma. When she presented, it was nine years after subtotal colectomy with ileoproctostomy for familial polyposis and eight years after abdominoperineal resection of the rectum with ileostomy for Dukes' B adenocarcinoma of the rectum. Her ileostomy had been revised seven years before this admission for peristomal skin irritation. She had a history of alcohol abuse and biopsy-proven cirrhosis, but had abstained from alcohol for several months before the current admission.
Volume 33
Number 4
T R E A T M E N T OF BLEEDING STOMAL VARICES
TABLE 1. Laboratory Values Units Hematocrit Total protein Albumin SGOT SGPT Alkaline phosphatase PT PTT Total bilirubin
percent mg/dl mg/dl IU/1 IU/1 IU/1 seconds seconds mg/dl
TABLE 2. Ostomy Type and Diagnoses
Postoperative Preoperative " (7 months) 19 6.4 3.0 42 24 93 12.8 29.6 0.4
309
36 7.9 3.3 67 30 139 13.4 42.9 0.8
Her first episode of ileostomy hemorrhage requiring treatment occurred three years before this admission with subsequent episodes following at intervals of 12, 26, 27, 32, 33, 34, and 35 months, respectively. Despite upper gastrointestinal endoscopy, ileoscopy, upper gastrointestinal series with small-bowel follow-through, and superior mesenteric arteriography, no bleeding point could be identified. The venous phase of the superior mesenteric arteriogram confirmed the presence of stomal varices at the ileostomy. Grade 1 nonbleeding esophageal varices were documented on upper gastrointestinal endoscopy. Each stomal bleeding episode had been treated successfully with local pressure, intravenous fluids, and blood transfusions; the patient refused other treatment options. A total of 41 units of packed red blood cells had been administered before this admission. Physical examination revealed hepatosplenomegaly, a lefi-sided ileostomy with fresh blood in the stomal appliance. No discrete varix or other source of bleeding was seen. A bluish discoloration was noted on the skin surrounding the stoma. The sclerae were anicteric and mild ascites was present. Laboratory values upon admission are listed in Table 1. Once again the patient responded to local measures and 5 units of packed red blood cells. She was discharged at her request but accepted a recommendation for portosystemic shunting. Two weeks after discharge she was a d m i t t e d electively a n d u n d e r w e n t portosystemic shunting with an 8-mm Gortex (W. L. Gore & Associates, Inc., Elkton, Maryland) interposition graft placed between the portal vein and the inferior vena cava. One unit of packed red blood cells was transfused perioperatively. The postoperative course was unremarkable and the patient was discharged on the fifth postoperative day. Laboratory values seven months postoperatively are listed in Table 1. Fifteen months after surgery the patient has had no further episodes of stomal bleeding and has no clinical evidence of encephalopathy.
Discussion
Since the first report of intestinal varices in t961 by Bloor and Orr ~7 and stomal varices by Reznick et al. is in 1968, many authors have reported their experience with single cases or small series. 1-35 In addition to the case reported here, a review of the English medical l i t e r a t u r e s i n c e 1967 r e v e a l e d 71 r e p o r t e d c a s e s o f b l e e d i n g s t o m a l v a r i c e s . O f t h i s t o t a l o f 72 cases, 49 i n v o l v e d i l e o s t o m y v a r i c e s , 15 i n v o l v e d c o l o s t o m y varices, and 8 involved ileal conduit varices. Ulcerative colitis was the most frequent indication for the creation of an ileostomy, while carcinoma of the rectum and carcinoma of the bladder were the most common
Diagnosis
Ileostomy
Ulcerative colitis Polyposis coli Crohn's disease Carcinoma of rectum Carcinoma of cervix Diverticulitis Carcinoma of bladder Carcinoma of urethra Other TOTAL
43 2 4 M M M M M M 49
Colostomy Ileal Conduit M M M 13 1 1 M M M 15
M M M M M M 5 1 2 8
indications for the creation of a colostomy and ileal conduit, respectively (Table 2). Primary sclerosing cholangitis in association with ulcerative colitis was the most frequent cause of portal hypertension. In patients with ileostomies, 73 percent had primary sclerosing cholangitis and 18 percent had alcoholic liver disease. Metastatic disease was the most common etiology in patients with colostomies (Table 3). A total of 31 male and 26 female patients were identified by gender. They were evenly distributed throughout the ileostomy, colostomy, and ileal conduit groups. The average age of male patients was 55.4 years and the average age of female patients was 49 years, with female patients younger in each group (Table 4). On physical examination, hepatosplenomegaly, ascites, and caput medusae were noted commonly (Table 5). Discrete stomal varices were found in all patients with bleeding from a colostomy or ileal conduit. Patients bleeding from an ileostomy reported either discrete varices or a caput medusae (82 percent), a bluish skin discoloration (13 percent), or no evidence of varices (5 percent) (Table 6). The interval from creation of the ostomy until the first incidence of bleeding for which medical attention was sought ranged from 2 to 348 months. The average interval was 48 months for ileostomy patients, 38 months for ileal conduit patients, and 23 months for
TABLE 3. Etiology of Portal Hypertension Diagnosis Alcohol induced Hepatitis Primary sclerosing cholangitis Metastatic colorectal carcinoma Secondary biliary cirrhosis Hypercholesterolemia Not reported
Ileostomy
Colostomy Ileal Conduit
7 1
2 2
2 1
29
M
M
M 3 M 12
4 M 1 6
M M M 5
310
CONTE, ET AL.
TABLE 4. Patient Characteristics
Dis.Col. &Rect. April 1990
TABLE 6. Physical Evidence of Varices
Sex Male Female Not specified TOTAL
C
IC
Total
17 18 14 49
9 6 M 15
5 2 1 8
31 26 15 72
I Male Female
Ileostomy
I
50y 47y
Average Age C IC 60y 56y
63y 41y
Visible varices Blue discoloration Caput medusae No evidence found Patients reporting
Colostomy Ileal Conduit
27 5 5 2 39
10 M M M 10
5 M M M 5
Total TABLE 7, Interval to First Bleed
55.4y 49y
colostomy patients. Median times were 20, 36, and 23 months, respectively (Table 7). Most bleeding episodes were not associated with symptoms. Diffuse abdominal pain was the most commonly reported symptom (Table 8). The concomitant presence of esophageal varices in patients with bleeding stomal varices was assessed by analyzing the results of upper gastrointestinal endoscopy in 38 patients. Esophageal varices were present in 74 percent of patients with ileostomy stomal varices, in 83 percent of patients with colostomy varices, and in 20 percent of patients with ileal conduit varices (Table 9). In the ileostomy group, 54 percent of patients had a previously documented incidence of esophageal variceal bleeding. Most patients with bleeding stomal varices had previously had multiple stomal hemorrhages requiring medical attention (Table 10). In the ileostomy group, 29 percent reported greater than 20 hemorrhages. In addition, many patients had multiple trivial bleeding episodes for which medical attention was not sought. The total transfusion requirements were substantial, particularly in the ileostomy group. Eight patients with ileostomies had between 11 and 20 units of blood and two patients in both the ileostomy and colostomy groups required a total of over 20 units of blood (Table 11). Methods used to evaluate patients included upper gastrointestinal and stomal endoscopy, arteriography, radionuclide scanning, upper gastrointestinal, and stomal contrast studies.
Ileostomy Number reported Range Average Median
23 5-348 mos 48 mos 20 mos
Colostomy Ileal Conduit 10 6-84 mos 23 mos 12 mos
6 2-84 mos 38 mos 36 mos
Stomal varices were identified on three occasions by stomal endoscopy, but a specific bleeding site was seen in only 1 of 14 patients examined. Arteriograms were performed in 30 patients and were successful in identifying varices in 28 patients when venous phase studies were performed. Arteriography was never able to identify a specific site of active bleeding (Table 12). Supportive treatment with intravenous fluids and blood transfusions alone, or in conjunction with local pressure, was the initial treatment most frequently performed for bleeding stomal varices. Sponges soaked in an epinephrine solution were occasionally used as an adjunct. Nearly all patients (98 percent) treated in this way, however, experienced rebleeding within 2 to 10 months. Only 11 patients had some type of operative intervention included as part of their initial treatment (Table 13). The first surgical procedure was performed at a mean of 14.6 months, and a median of 10 months, after the
TABLE 8. Symptoms Ileostomy Number reported 11 No symptoms 10 (91 percent) Pain 1 (9 percent)
Colostomy
Ileal Conduit
10 9 (90 percent) 1 (10 percent)
7 6 (86 percent) 1 (14 percent)
TABLE 5. Physical Examination Finding Hepatomegaly Splenomegaly Ascites Caput medusae Spider angiomata Jaundice Skin changes Patients reporting
Ileostomy 6 8 3 5 M 1 3 15
Colostomy Ileal Conduit 1 1 M 1 M 1 M 4
2 1 2 2 M 1 M 6
TABLE 9. Esophageal Varices Ileostomy Present on endoscopy 20 (74 percent) Bleeding 7 Not bleeding 6 Not mentioned 7 Not present on endoscopy 7
Colostomy
Ileal Conduit
5 (83 percent) 0 2 3
1 (20 percent) 0 0 1
1
4
V o l u m e 33
311
TREATMENT OF BLEEDING STOMAL VARICES
Number 4
TABLE 10. Ostom~)Hemorrhages Number of Hemorrhages Specified no. reported 1-5 6-10 11-20 > 20 Multiple reported
Ileostomy 17 7 (41%) 4 (24%) 1 (6%0 5 (29%) 23
TABLE12. Methods of Evaluation
Colostomy Ileal Conduit 6 4 (67%) 1 (16%) 1 (16%) M 7
2 1 (50%) 1 (50%) M M 4
first episode of bleeding in all patients. T h e initial surgical procedure most c o m m o n l y performed was stomal m a n i p u l a t i o n , followed by suture ligation of varices (Table 13). Stomal m a n i p u l a t i o n included any procedure that divided the connections between the portal venous system and the systemic venous system in the subcutaneous tissue of the a b d o m i n a l wall and ranged from the local portosystemic disconnection described by Fazio et al.2,11 to a formal takedown and relocation of the ostomy. Advocates of m u c o c u t a n e o u s dislocation believe the procedure is relatively m i n o r and m a y be repeated if necessary. Blood loss is m i n i m a l and the postoperative recovery period brief. 11 It m a y be performed under local or general anesthesia. Stomal relocation is a more maj or procedure requiring an average hospital stay of three weeks and with reported transfusion requirements of 2 to 31 units of packed red blood cells, n When stomal m a n i p u l a t i o n was performed as the initial treatment, all patients experienced rebleeding within nine months, and 54 percent had multiple episodes, suggesting that portosystemic connections reform after they are divided because the underlying h i g h portal pressure has not been treated. Of patients w h o h a d ileostomy revisions, 40 percent had multiple revisions and 66 percent had additional procedures performed. Survival averaged 2.5 years after stomal m a n i p u l a t i o n in one recent series, la Suture ligation of an individual varix was performed in one third of all patients, in half of these patients as the initial procedure. All patients (100 percent) had recurrent bleeding two to eight m o n t h s after ligation. T h i s is a simple but ineffective long-term treatment, best reserved for those patients with short life expectancy
Stomal Endoscopy
Ileostomy
Times performed Varices identified Bleeding site identified Arteriogram
14 3 1 Ileostomy
Times performed Varices identified Bleeding site localized
21 18 0
Colostomy Ileal Conduit 4 0 0
1 0 0
Colostomy Ileal Conduit 5 5 0
4 4 0
or those w h o are prohibitive surgical risks for more m a j o r surgery. Sclerotherapy has been performed for all types of stomal bleeding.I, x5 It is m i n i m a l l y invasive, b u t requires multiple injections and has a high incidence of rebleeding (100 percent). Although some authors r e c o m m e n d sclerotherapy as the initial procedure, the h i g h recurrence rate and requirement for multiple sessions make this a procedure best reserved for patients unable to undergo other procedures. Beta blockade with p r o p a n o l o l has been reported in one patient with bleeding stomal varices, and was ineffective. 16 Portosystemic s h u n t i n g has been performed less often than stomal m a n i p u l a t i o n , and usually only after other modalities failed. Only eight patients had a shunting procedure as the first procedure, while 33 percent had one p r o c e d u r e a n d 40 percent h a d two or m o r e procedures performed before shunting. Additionally, 60 percent of ileostomy patients w h o underwent s h u n t i n g h a d p r e v i o u s l y h a d a s t o m a l revision. S h u n t i n g procedures had the lowest incidence of rebleeding. No patients with ileostomy or colostomy variceal bleeding w h o underwent a s h u n t i n g procedure experienced rebleeding (average follow-up period, 31 months). Average survival after s h u n t i n g was longer than for any other treatment. In patients with ileostomies, the average survival time was 2 m o n t h s after variceal ligation, 15 m o n t h s after stomal revision, and 50 m o n t h s after shunting. Some authors believe that s h u n t i n g will accelerate liver failure and assume that the morbidity and mortality
TABLE 13. Initial Treatment TABLEll. TransJusions UUnits of PRBC 0 1-5 6-10 11-20
More than 20 Multiple
Ileostomy
Type
Colostomy Ileal Conduit
M 2 k
M 1 M
M M M
8
M
M
2 12
2 4
M M
Supportive Local pressure Suture ligature Sclerotherapy Stoma~l'manipulation -, , , ~ . Shunt ~ Unclear
Ileostomy 10 19 4 M M M 16
Colostomy Ileal Conduit 1 3 3 M 1 M 7
4 M 2 M 1 M 1
3 12
Dis. Col. g: Rect.
CONTE, ET AL.
TABLE 18. Number of Procedures Before Shunt
TABLE 14. Initial Procedure Type
Ileostomy
Stomal manipulation Suture ligation Shunt Exploratory laparotomy Sclerotherapy Unclear
Colostomy Ileal Conduit
15 9 4 2 M 19
6 6 2 M 1 1
2 3 2 M 1 1
TABLE 15. Total Procedures Type
Ileostomy
Stomal manipulation Shunt Suture ligation Sclerotherapy Exploratory laparotomy No procedure Patients reporting
Colostomy Ileal Conduit
26 22 14 3 3 5 44
8 2 6 4 M M 15
April 1990
6 3 4 M M M 8
associated with shunting for esophageal bleeding is the same for shunting to treat stornal bleeding.2, 5 In our review, however, overall morbidity was low. In particular, the absence of postoperative hepatic encephalopathy in the ileostomy group may be attributed to the absence of the colon, the major source of bacteria-generated nitrogenous products. In terms of total procedures performed, stomal manipulation was the most frequent procedure (Table
Number
4
2
2
1
5
M
M
2 2 2 7 22
M M M M 2
M M M M 2
2 3 More than 4 Undetermined TOTAL
14) and was performed in 60 percent of patients with ileostomies, 53 percent of patients with colostomies, and 75 percent of patients with ileal conduits. A shunting procedure was performed in 50 percent of patients with ileostomies, 37 percent of patients with ileal conduits, and 13 percent of patients with colostomies. Suture ligation of varices was performed in greater than one third of the patients in each group. Multiple procedures were performed in most patients, and in some, the same procedure was performed several times. Suture ligation was performed more than once for bleeding stomal varices in 57 percent of ileostomy patients, in 71 percent of colostomy patients, and in 75 percent of ileal conduit patients. Sclerotherapy was performed infrequently and repeat injections were required in approximately two thirds of those patients receiving sclerotherapy (Table
15). Stomal revisions were performed in 40 patients. Stomal revisions were performed more than once in TABLE 19. Incidence of Rebleeding
Colostomy Ileal Conduit
Bleeding episodes None Single Multiple
5 12 14
3 2 2
3 1 2
Additional procedures None Single Multiple
10 6 13
5 1 1
3 1 2
Procedure Ligation Revision Sclerotherapy Shunt Exploratory laparotomy Not included
Ileostomy
Portacaval
Colostomy
Ileal Conduit
9/9 (100 percent) 5/6 (83 percent) 3/3 (100 percent) 13/18(72 percent) 3/6 (50 percent) M M 1/1 (100 percent) M 0/6 (0 percent) 0/2 (0 percent) 1/2 (50 percent) 1/1 (100 percent) M
M M
M 1
TABLE 20. Deaths
TABLE 17. Total Shunts Ileostomy
Colostomy Ileal Conduit
0
TABLE 16. Stomal Revision Ileostomy
Ileostomy
Ileostomy
Colostomy Ileal Conduit
9
1
1
End-to-side Side-to-side Interposition Splenorenal
7 1 1 11
1 M M M
1 M M 2
Central Distal Mesocaval
11 0 2
M M 1
2 0 M
22
2
3
Total deaths Average time from first procedure Ligation Revision Sclerotherapy Average time from last procedure Ligation Revision Shunt
Colostomy Ileal Conduit
21
9
3
45m 65 37 M
19m 3 30 9
31m 5 1 M
34m 2 15 50
20m 3 30 --
7m 14 14 M
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313
T R E A T M E N T OF BLEEDING STOMAL VARICES
42 percent of patients with ileostomies and in 33 percent of patients with ileal conduits. Additionally, after failed stomal revisions, subsequent other procedures were performed in 66 percent of ileostomy patients, 29 percent of colostomy patients, and 50 percent of ileal conduit patients (Table 16). A total of 27 patients had a surgical shunting procedure performed. Central splenorenal shunts were performed most commonly. Thirteen patients received splenorenal shunts, 11 received portacaval shunts, and 3 received mesocaval shunts (Table 17). Seventy-four percent of patients who underwent portosystemic shunting had previously had a surgical procedure performed and multiple prior procedures had been performed in 55 percent of these patients (Table 18). Stomal revisions were performed 60 percent of the time before shunting with multiple revisions performed in 45 percent of the patients. Rebleeding was evaluated after the initial procedure. Rebleeding occurred in nearly all patients if their inital treatment was a stomal revision, oversewing of varices, or local supportive treatment. The lowest incidence of rebleeding was in the portosystemic shunt group. No patient experienced rebleeding after a shunt for ileostomy or colostomy bleeding. One patient with an ileal conduit rebled for an overall recurrence of 10 percent. Variceal ligation had a 95 percent recurrence rate and stomal revisions a 73 percent recurrence rate when performed as the initial surgical procedure (Table 19). In the ileostomy group, the time interval from the initial procedure until the first episode of rebleeding averaged six months after stomal revision and 9 months after variceal ligation. A total of 33 deaths were reported in the articles reviewed. Twenty-one patients had ileostomies, nine had colostomies, and three had ileal conduits. None of the eight patients who had shunting procedures performed as the intial procedure had died at followup of 14, 14, 27, and 84 months, respectively, for the ileostomy patients, 4 and 120 months, respectively, for the colostomy patients, and 18 months for the ileal conduit patient. The time from the last procedure performed until the time of death was evaluated also. Patients with ileostomies lived an average of 2 months after variceal ligation, 15 months after stomal revision, and 50 months after shunting (Table 20). All treatment of bleeding stomal varices is palliative. The most efficacious treatment should stop bleeding without recurrence, have low morbidity, prolong survival, and be cost effective. Based on these criteria, early portosystemic shunting appears to be the best treatment for bleeding stomal varices. It offers the lowest rates of rebleeding and need
for further surgery, the longest survival, and the lowest risk of encephalopathy. Shunting is associated with fewer hospitalizations, fewer procedures, and fewer transfusions than other procedures and thus is the most cost-effective option available. Portosystemic shunting, however, should be restricted to those patients who can tolerate major surgery and who have a reasonable life expectancy. Suture ligation or sclerotherapy should be employed in patients with end-stage disease, with stomal revision used in all other patients.
References 1. Hesterberg R, Stahlknecht CD, Roher HD. Sclerotherapy for massive enterostomy bleeding resulting from portal hypertension. Dis Colon Rectum 1986;29:275-7. 2. Grundfest-Broniatowski S, Fazio V. Conservative treatment of bleeding stomal varices. Arch Surg 1983;118:981-5. 3. Cameron AD, Fone DJ. Portal hypertension and bleeding ileal varices after colectomy and ileostomy for chronic ulcerative colitis. Gut 1970;11:755-9. 4. Eade MN, Williams JA, Cooke UT. Bleeding from an ileostomy caput medusae. Lancet 1969;2:1166-8. 5. Peck J J, Boyden AM. Exigent ileostomy hemorrhage. Am J Surg 1985;150:153-8. 6. Cooper MJ, Mackie CR, Dhorajiwala J, Baker AL, Moose RA. Hemorrhage from ileal varices after total proctocolectomy. Am J Surg 1981;141:178-9. 7. Ricci RL, Leek R, Greenberger NJ. Chronic gastrointestinal bleeding from ileal varices after total proctocolectomy for ulcerative colitis: correction by mesocaval shunt. Gastroenterology 1980;78:1053-8. 8. Adson MA, Fulton RE. The ileal stoma and portal hypertension. Arch Surg 1977;112:501-4. 9. Graeber GM, Ramer MH, Ackerman NB. Massive hemorrhage from ileostomy and colostomy stomas due to mucocutaneous varices in patients with coexisting cirrhosis. Surgery 1976;79:10710. 10. Foulke J, Wallace DM. Hemorrhage from stomal varices in an ileal conduit. Br J Urol 1975;47:630. 11. Beck DE, Fazio VW, Grundfest-Broniatowski S. Surgical management of bleeding stomal varices. Dis Colon Rectum 1988;31:343-6. 12. Wang MM, McGrew W, Dunn GD. Variceal bleeding from an ileostomy stoma. South Med J 1985;78:733-7. 13. Goldstein WZ, Edoga J, Crystal R. Management of colostomal hemorrhage resulting from portal hypertension. Dis Colon Rectum 1980;23:86-90. 14. Ackerman MB, Graeber GM, Frey J. Enterostomal varices secondary to portal hypertension. Arch Surg 1980;115:1454-5. 15. Morgan TR, Feldshon SD, Tripp MR. Recurrent stomal bleeding: successful treatment using injection sclerotherapy. Dis Colon Rectum 1986;29:269-70. 16. Chapman ML, Janowitz HD. Chronic portal systemic encephalopathy after ileostomy a n d colonic resection. Lancet 1966;2:1064-5. 17. Bloor K, Orr W. A case of hemorrhage from varices in the small intestine due to portal hypertension. Br J Surg 1961;48:4234. 18. Reznick RH, Ishihara A, Chalmers TC, Schimmel, Boston InterHospital Liver Group. A controlled trial of colon bypass in chronic hepatic encephalopathy. Gastroenterology 1968;54:1057-69. 19. Crooks RR, Hensle TW, Heney NM, Wahman A, Irwin RJ. Ileal conduit hemorrhage secondary to portal hypertension. Urology 1978; 12:689-93. 20. Firlit RS, Firlit CF, Canning J. Exsanguinating hemorrhage from
314
21. 22. 23. 24. 25.
26. 27. 28.
CONTE, ET AL.
urinary ileal conduit in patient with portal hypertension. Urology 1978;12:710-11. Perrault JP, Laroze M, Faucher R, et al. Hemorrhage d'un conduit ileal secondaire a une hypertension portale. J Urol (Paris) 1982;88:47-9. Lebrec D, Benhamou J-P. Ectopic varices in portal hypertension clinics. Gastroenterology 1985;14:105-21. Federle M, Clark RA. Mesenteric varices: a source of mesosystemic shunts and gastrointestinal hemorrhage. Gastrointest Radiol 1979;4:331-7. Johnson AG, Simms JM. Correspondence. Br J Surg 1983;70:187. Falchuk KR, Aiello MR, Trey C, Costello P. Recurrent bleeding from ileal varices associated with intraabdominal adhesions: case report and review of the literature. Am J Gastroenterol 1982;77:859-60. Hollands JM. Parastomal hemorrhage from an ileal conduit secondary to portal hypertension. Br J Surg 1982;69:675. Eckhauser FE, Sonda LP, Strodel WE, Edgcomb LP, Turcotte JG. Parastomal ileal conduit hemorrhage and portal hypertension. Ann Surg 1980;5:620-4. Finemore RG. Repeated hemorrhage from a terminal colostomy due to mucocutaneous varices with coexisting metastatic rectal adenocarcinoma. Br J Surg 1979;66:806.
Dis. Col. ~ Rect. April 1990
29. Gray RK, Grollman JH. Acute lower GI bleeding secondary to varices of the superior mesenteric venous system. Radiology 1974;111:559-61. 30. Hamlyn AN, Morris JS, Lunzer MR, Puritz H, Dick R. Portal hypertension with varices in unusual sites. Lancet 1974;2:15314. 31. Moncure AC, Waltman AC, Vandersalm TJ, Linton RR, Levine FH, Abbott WM. Gastrointestinal hemorrhage from adhesion related mesenteric varices. Ann Surg 1976;183:24-9. 32. Freed JS, Szuchmacher PH, Bluestone L, Fano A. Massive colonic variceal bleeding secondary to abnormal splenocolic collaterals: report of a case. Dis Colon Rectum 1978;21:126-7. 33. Goldstein MD, Vrandt LD, Bernstein LH. Hemorrhage from ileal varices: a unusual complication after total portocolectomy in a patient with ulcerative colitis and cirrhosis. Am J Gastroenterol 1983;78:351-4. 34. Wiesner RH, Beaver SJ, LaRusso NF. Bleeding peristomal varices: a serious complication of proctocolectomy for chronic ulcerative colitis in patients with primary sclerosing cholangitis. Hepatology 1982;2:699. 35. Watlans RM. Variceal hemorrhage from a colostomy due to portal hypertension secondary to intrahepatic metastases from rectal carcinoma. Br Med J 1981;282:189-90.
of a Case
and
Review
of the Literature
J O H N V. CONTE, M . D . , T O D D A. ARCOMANO, M . D . , MOHAMMED A. NAFICY, M . D . , RICHARD W. H O L T , M . D .
Conte JV, Arcomano TA, Naficy MA, Holt RW. Treatment of bleeding stomal varices: report of a case and review of the literature. Dis Colon Rectum 1990;33:308-314. Variceal bleeding from ileostomy, colostomy, or ileal conduit stomas is unusual. There is no consensus on which of the various treatment options is best. A case of bleeding ileostomy varices is presented. The English-language medical literature since 1962 is reviewed and an additional 71 cases of stomal variceal bleeding are identified. Treatment options evaluated include stomal manipulation, variceal ligation, sclerotherapy, beta blockade, and surgical shunting. The incidence of rebleeding, requirement for additional procedures, and survival with the various options are compared. Although stomal manipulation was the most commonly performed procedure, portosystemic shunting had the lowest incidence of both rebleeding and need for additional procedures (4 percent each) and provided the longest mean postoperative survival (50 months). The authors conclude that portosystemic shunting is the treatment of choice in patients with bleeding from stomal varices who are good surgical candidates. [Key words: Portal hypertension; Stomal varices; Portocaval shunt] VARICEAL BLEEDING f r o m c o l o s t o m y , i l e o s t o m y , o r ileal c o n d u i t s t o m a s is a n u n u s u a l c o m p l i c a t i o n of p o r t a l hypertension. T h e b l e e d i n g o r i g i n a t e s f r o m e n t e r o s t o m a l varices located at the level of the m u c o c u t a n e o u s b o r d e r of the stoma. T h e s e variees are the result of a n a s t a m o s e s b e t w e e n the h i g h - p r e s s u r e p o r t a l v e n o u s system a n d the l o w pressure systemic v e n o u s system a r o u n d the stoma. 1-4
9Address reprint requests to Dr. Holt: Department of Surgery, Georgetown University Medical Center, 3800 Reservoir Rd., N.W., Washington, D.C. 20007.
308
From the Department of Surgery, Georgetown University Medical Center, and Georgetown University Surgical Division, District of Columbia General Hospital Washington, District of Columbia
Bleeding can arise spontaneously as a result of erosion of a submucosal varix or from local trauma. Treatment options include portosystemic shunting? -9 stomal revisions or disconnections,2,1~ ix bowel resection, 4 ligation of individual varices,9,12-14 sclerotherapy?, 15 beta blockade, TM and direct local pressure. A l t h o u g h there are m a n y treatment modalities available, no consensus exists on which treatment is best. In this article, a case of bleeding ileostomy varices is reported and a review of the English-language medical literature since 1962 to assess the efficacy of the various treatment options. Report of a Case A 35-year-old black woman presented in the emergency room of the hospital with her eighth documented episode of bleeding from an ileostomy stoma. When she presented, it was nine years after subtotal colectomy with ileoproctostomy for familial polyposis and eight years after abdominoperineal resection of the rectum with ileostomy for Dukes' B adenocarcinoma of the rectum. Her ileostomy had been revised seven years before this admission for peristomal skin irritation. She had a history of alcohol abuse and biopsy-proven cirrhosis, but had abstained from alcohol for several months before the current admission.
Volume 33
Number 4
T R E A T M E N T OF BLEEDING STOMAL VARICES
TABLE 1. Laboratory Values Units Hematocrit Total protein Albumin SGOT SGPT Alkaline phosphatase PT PTT Total bilirubin
percent mg/dl mg/dl IU/1 IU/1 IU/1 seconds seconds mg/dl
TABLE 2. Ostomy Type and Diagnoses
Postoperative Preoperative " (7 months) 19 6.4 3.0 42 24 93 12.8 29.6 0.4
309
36 7.9 3.3 67 30 139 13.4 42.9 0.8
Her first episode of ileostomy hemorrhage requiring treatment occurred three years before this admission with subsequent episodes following at intervals of 12, 26, 27, 32, 33, 34, and 35 months, respectively. Despite upper gastrointestinal endoscopy, ileoscopy, upper gastrointestinal series with small-bowel follow-through, and superior mesenteric arteriography, no bleeding point could be identified. The venous phase of the superior mesenteric arteriogram confirmed the presence of stomal varices at the ileostomy. Grade 1 nonbleeding esophageal varices were documented on upper gastrointestinal endoscopy. Each stomal bleeding episode had been treated successfully with local pressure, intravenous fluids, and blood transfusions; the patient refused other treatment options. A total of 41 units of packed red blood cells had been administered before this admission. Physical examination revealed hepatosplenomegaly, a lefi-sided ileostomy with fresh blood in the stomal appliance. No discrete varix or other source of bleeding was seen. A bluish discoloration was noted on the skin surrounding the stoma. The sclerae were anicteric and mild ascites was present. Laboratory values upon admission are listed in Table 1. Once again the patient responded to local measures and 5 units of packed red blood cells. She was discharged at her request but accepted a recommendation for portosystemic shunting. Two weeks after discharge she was a d m i t t e d electively a n d u n d e r w e n t portosystemic shunting with an 8-mm Gortex (W. L. Gore & Associates, Inc., Elkton, Maryland) interposition graft placed between the portal vein and the inferior vena cava. One unit of packed red blood cells was transfused perioperatively. The postoperative course was unremarkable and the patient was discharged on the fifth postoperative day. Laboratory values seven months postoperatively are listed in Table 1. Fifteen months after surgery the patient has had no further episodes of stomal bleeding and has no clinical evidence of encephalopathy.
Discussion
Since the first report of intestinal varices in t961 by Bloor and Orr ~7 and stomal varices by Reznick et al. is in 1968, many authors have reported their experience with single cases or small series. 1-35 In addition to the case reported here, a review of the English medical l i t e r a t u r e s i n c e 1967 r e v e a l e d 71 r e p o r t e d c a s e s o f b l e e d i n g s t o m a l v a r i c e s . O f t h i s t o t a l o f 72 cases, 49 i n v o l v e d i l e o s t o m y v a r i c e s , 15 i n v o l v e d c o l o s t o m y varices, and 8 involved ileal conduit varices. Ulcerative colitis was the most frequent indication for the creation of an ileostomy, while carcinoma of the rectum and carcinoma of the bladder were the most common
Diagnosis
Ileostomy
Ulcerative colitis Polyposis coli Crohn's disease Carcinoma of rectum Carcinoma of cervix Diverticulitis Carcinoma of bladder Carcinoma of urethra Other TOTAL
43 2 4 M M M M M M 49
Colostomy Ileal Conduit M M M 13 1 1 M M M 15
M M M M M M 5 1 2 8
indications for the creation of a colostomy and ileal conduit, respectively (Table 2). Primary sclerosing cholangitis in association with ulcerative colitis was the most frequent cause of portal hypertension. In patients with ileostomies, 73 percent had primary sclerosing cholangitis and 18 percent had alcoholic liver disease. Metastatic disease was the most common etiology in patients with colostomies (Table 3). A total of 31 male and 26 female patients were identified by gender. They were evenly distributed throughout the ileostomy, colostomy, and ileal conduit groups. The average age of male patients was 55.4 years and the average age of female patients was 49 years, with female patients younger in each group (Table 4). On physical examination, hepatosplenomegaly, ascites, and caput medusae were noted commonly (Table 5). Discrete stomal varices were found in all patients with bleeding from a colostomy or ileal conduit. Patients bleeding from an ileostomy reported either discrete varices or a caput medusae (82 percent), a bluish skin discoloration (13 percent), or no evidence of varices (5 percent) (Table 6). The interval from creation of the ostomy until the first incidence of bleeding for which medical attention was sought ranged from 2 to 348 months. The average interval was 48 months for ileostomy patients, 38 months for ileal conduit patients, and 23 months for
TABLE 3. Etiology of Portal Hypertension Diagnosis Alcohol induced Hepatitis Primary sclerosing cholangitis Metastatic colorectal carcinoma Secondary biliary cirrhosis Hypercholesterolemia Not reported
Ileostomy
Colostomy Ileal Conduit
7 1
2 2
2 1
29
M
M
M 3 M 12
4 M 1 6
M M M 5
310
CONTE, ET AL.
TABLE 4. Patient Characteristics
Dis.Col. &Rect. April 1990
TABLE 6. Physical Evidence of Varices
Sex Male Female Not specified TOTAL
C
IC
Total
17 18 14 49
9 6 M 15
5 2 1 8
31 26 15 72
I Male Female
Ileostomy
I
50y 47y
Average Age C IC 60y 56y
63y 41y
Visible varices Blue discoloration Caput medusae No evidence found Patients reporting
Colostomy Ileal Conduit
27 5 5 2 39
10 M M M 10
5 M M M 5
Total TABLE 7, Interval to First Bleed
55.4y 49y
colostomy patients. Median times were 20, 36, and 23 months, respectively (Table 7). Most bleeding episodes were not associated with symptoms. Diffuse abdominal pain was the most commonly reported symptom (Table 8). The concomitant presence of esophageal varices in patients with bleeding stomal varices was assessed by analyzing the results of upper gastrointestinal endoscopy in 38 patients. Esophageal varices were present in 74 percent of patients with ileostomy stomal varices, in 83 percent of patients with colostomy varices, and in 20 percent of patients with ileal conduit varices (Table 9). In the ileostomy group, 54 percent of patients had a previously documented incidence of esophageal variceal bleeding. Most patients with bleeding stomal varices had previously had multiple stomal hemorrhages requiring medical attention (Table 10). In the ileostomy group, 29 percent reported greater than 20 hemorrhages. In addition, many patients had multiple trivial bleeding episodes for which medical attention was not sought. The total transfusion requirements were substantial, particularly in the ileostomy group. Eight patients with ileostomies had between 11 and 20 units of blood and two patients in both the ileostomy and colostomy groups required a total of over 20 units of blood (Table 11). Methods used to evaluate patients included upper gastrointestinal and stomal endoscopy, arteriography, radionuclide scanning, upper gastrointestinal, and stomal contrast studies.
Ileostomy Number reported Range Average Median
23 5-348 mos 48 mos 20 mos
Colostomy Ileal Conduit 10 6-84 mos 23 mos 12 mos
6 2-84 mos 38 mos 36 mos
Stomal varices were identified on three occasions by stomal endoscopy, but a specific bleeding site was seen in only 1 of 14 patients examined. Arteriograms were performed in 30 patients and were successful in identifying varices in 28 patients when venous phase studies were performed. Arteriography was never able to identify a specific site of active bleeding (Table 12). Supportive treatment with intravenous fluids and blood transfusions alone, or in conjunction with local pressure, was the initial treatment most frequently performed for bleeding stomal varices. Sponges soaked in an epinephrine solution were occasionally used as an adjunct. Nearly all patients (98 percent) treated in this way, however, experienced rebleeding within 2 to 10 months. Only 11 patients had some type of operative intervention included as part of their initial treatment (Table 13). The first surgical procedure was performed at a mean of 14.6 months, and a median of 10 months, after the
TABLE 8. Symptoms Ileostomy Number reported 11 No symptoms 10 (91 percent) Pain 1 (9 percent)
Colostomy
Ileal Conduit
10 9 (90 percent) 1 (10 percent)
7 6 (86 percent) 1 (14 percent)
TABLE 5. Physical Examination Finding Hepatomegaly Splenomegaly Ascites Caput medusae Spider angiomata Jaundice Skin changes Patients reporting
Ileostomy 6 8 3 5 M 1 3 15
Colostomy Ileal Conduit 1 1 M 1 M 1 M 4
2 1 2 2 M 1 M 6
TABLE 9. Esophageal Varices Ileostomy Present on endoscopy 20 (74 percent) Bleeding 7 Not bleeding 6 Not mentioned 7 Not present on endoscopy 7
Colostomy
Ileal Conduit
5 (83 percent) 0 2 3
1 (20 percent) 0 0 1
1
4
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TREATMENT OF BLEEDING STOMAL VARICES
Number 4
TABLE 10. Ostom~)Hemorrhages Number of Hemorrhages Specified no. reported 1-5 6-10 11-20 > 20 Multiple reported
Ileostomy 17 7 (41%) 4 (24%) 1 (6%0 5 (29%) 23
TABLE12. Methods of Evaluation
Colostomy Ileal Conduit 6 4 (67%) 1 (16%) 1 (16%) M 7
2 1 (50%) 1 (50%) M M 4
first episode of bleeding in all patients. T h e initial surgical procedure most c o m m o n l y performed was stomal m a n i p u l a t i o n , followed by suture ligation of varices (Table 13). Stomal m a n i p u l a t i o n included any procedure that divided the connections between the portal venous system and the systemic venous system in the subcutaneous tissue of the a b d o m i n a l wall and ranged from the local portosystemic disconnection described by Fazio et al.2,11 to a formal takedown and relocation of the ostomy. Advocates of m u c o c u t a n e o u s dislocation believe the procedure is relatively m i n o r and m a y be repeated if necessary. Blood loss is m i n i m a l and the postoperative recovery period brief. 11 It m a y be performed under local or general anesthesia. Stomal relocation is a more maj or procedure requiring an average hospital stay of three weeks and with reported transfusion requirements of 2 to 31 units of packed red blood cells, n When stomal m a n i p u l a t i o n was performed as the initial treatment, all patients experienced rebleeding within nine months, and 54 percent had multiple episodes, suggesting that portosystemic connections reform after they are divided because the underlying h i g h portal pressure has not been treated. Of patients w h o h a d ileostomy revisions, 40 percent had multiple revisions and 66 percent had additional procedures performed. Survival averaged 2.5 years after stomal m a n i p u l a t i o n in one recent series, la Suture ligation of an individual varix was performed in one third of all patients, in half of these patients as the initial procedure. All patients (100 percent) had recurrent bleeding two to eight m o n t h s after ligation. T h i s is a simple but ineffective long-term treatment, best reserved for those patients with short life expectancy
Stomal Endoscopy
Ileostomy
Times performed Varices identified Bleeding site identified Arteriogram
14 3 1 Ileostomy
Times performed Varices identified Bleeding site localized
21 18 0
Colostomy Ileal Conduit 4 0 0
1 0 0
Colostomy Ileal Conduit 5 5 0
4 4 0
or those w h o are prohibitive surgical risks for more m a j o r surgery. Sclerotherapy has been performed for all types of stomal bleeding.I, x5 It is m i n i m a l l y invasive, b u t requires multiple injections and has a high incidence of rebleeding (100 percent). Although some authors r e c o m m e n d sclerotherapy as the initial procedure, the h i g h recurrence rate and requirement for multiple sessions make this a procedure best reserved for patients unable to undergo other procedures. Beta blockade with p r o p a n o l o l has been reported in one patient with bleeding stomal varices, and was ineffective. 16 Portosystemic s h u n t i n g has been performed less often than stomal m a n i p u l a t i o n , and usually only after other modalities failed. Only eight patients had a shunting procedure as the first procedure, while 33 percent had one p r o c e d u r e a n d 40 percent h a d two or m o r e procedures performed before shunting. Additionally, 60 percent of ileostomy patients w h o underwent s h u n t i n g h a d p r e v i o u s l y h a d a s t o m a l revision. S h u n t i n g procedures had the lowest incidence of rebleeding. No patients with ileostomy or colostomy variceal bleeding w h o underwent a s h u n t i n g procedure experienced rebleeding (average follow-up period, 31 months). Average survival after s h u n t i n g was longer than for any other treatment. In patients with ileostomies, the average survival time was 2 m o n t h s after variceal ligation, 15 m o n t h s after stomal revision, and 50 m o n t h s after shunting. Some authors believe that s h u n t i n g will accelerate liver failure and assume that the morbidity and mortality
TABLE 13. Initial Treatment TABLEll. TransJusions UUnits of PRBC 0 1-5 6-10 11-20
More than 20 Multiple
Ileostomy
Type
Colostomy Ileal Conduit
M 2 k
M 1 M
M M M
8
M
M
2 12
2 4
M M
Supportive Local pressure Suture ligature Sclerotherapy Stoma~l'manipulation -, , , ~ . Shunt ~ Unclear
Ileostomy 10 19 4 M M M 16
Colostomy Ileal Conduit 1 3 3 M 1 M 7
4 M 2 M 1 M 1
3 12
Dis. Col. g: Rect.
CONTE, ET AL.
TABLE 18. Number of Procedures Before Shunt
TABLE 14. Initial Procedure Type
Ileostomy
Stomal manipulation Suture ligation Shunt Exploratory laparotomy Sclerotherapy Unclear
Colostomy Ileal Conduit
15 9 4 2 M 19
6 6 2 M 1 1
2 3 2 M 1 1
TABLE 15. Total Procedures Type
Ileostomy
Stomal manipulation Shunt Suture ligation Sclerotherapy Exploratory laparotomy No procedure Patients reporting
Colostomy Ileal Conduit
26 22 14 3 3 5 44
8 2 6 4 M M 15
April 1990
6 3 4 M M M 8
associated with shunting for esophageal bleeding is the same for shunting to treat stornal bleeding.2, 5 In our review, however, overall morbidity was low. In particular, the absence of postoperative hepatic encephalopathy in the ileostomy group may be attributed to the absence of the colon, the major source of bacteria-generated nitrogenous products. In terms of total procedures performed, stomal manipulation was the most frequent procedure (Table
Number
4
2
2
1
5
M
M
2 2 2 7 22
M M M M 2
M M M M 2
2 3 More than 4 Undetermined TOTAL
14) and was performed in 60 percent of patients with ileostomies, 53 percent of patients with colostomies, and 75 percent of patients with ileal conduits. A shunting procedure was performed in 50 percent of patients with ileostomies, 37 percent of patients with ileal conduits, and 13 percent of patients with colostomies. Suture ligation of varices was performed in greater than one third of the patients in each group. Multiple procedures were performed in most patients, and in some, the same procedure was performed several times. Suture ligation was performed more than once for bleeding stomal varices in 57 percent of ileostomy patients, in 71 percent of colostomy patients, and in 75 percent of ileal conduit patients. Sclerotherapy was performed infrequently and repeat injections were required in approximately two thirds of those patients receiving sclerotherapy (Table
15). Stomal revisions were performed in 40 patients. Stomal revisions were performed more than once in TABLE 19. Incidence of Rebleeding
Colostomy Ileal Conduit
Bleeding episodes None Single Multiple
5 12 14
3 2 2
3 1 2
Additional procedures None Single Multiple
10 6 13
5 1 1
3 1 2
Procedure Ligation Revision Sclerotherapy Shunt Exploratory laparotomy Not included
Ileostomy
Portacaval
Colostomy
Ileal Conduit
9/9 (100 percent) 5/6 (83 percent) 3/3 (100 percent) 13/18(72 percent) 3/6 (50 percent) M M 1/1 (100 percent) M 0/6 (0 percent) 0/2 (0 percent) 1/2 (50 percent) 1/1 (100 percent) M
M M
M 1
TABLE 20. Deaths
TABLE 17. Total Shunts Ileostomy
Colostomy Ileal Conduit
0
TABLE 16. Stomal Revision Ileostomy
Ileostomy
Ileostomy
Colostomy Ileal Conduit
9
1
1
End-to-side Side-to-side Interposition Splenorenal
7 1 1 11
1 M M M
1 M M 2
Central Distal Mesocaval
11 0 2
M M 1
2 0 M
22
2
3
Total deaths Average time from first procedure Ligation Revision Sclerotherapy Average time from last procedure Ligation Revision Shunt
Colostomy Ileal Conduit
21
9
3
45m 65 37 M
19m 3 30 9
31m 5 1 M
34m 2 15 50
20m 3 30 --
7m 14 14 M
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T R E A T M E N T OF BLEEDING STOMAL VARICES
42 percent of patients with ileostomies and in 33 percent of patients with ileal conduits. Additionally, after failed stomal revisions, subsequent other procedures were performed in 66 percent of ileostomy patients, 29 percent of colostomy patients, and 50 percent of ileal conduit patients (Table 16). A total of 27 patients had a surgical shunting procedure performed. Central splenorenal shunts were performed most commonly. Thirteen patients received splenorenal shunts, 11 received portacaval shunts, and 3 received mesocaval shunts (Table 17). Seventy-four percent of patients who underwent portosystemic shunting had previously had a surgical procedure performed and multiple prior procedures had been performed in 55 percent of these patients (Table 18). Stomal revisions were performed 60 percent of the time before shunting with multiple revisions performed in 45 percent of the patients. Rebleeding was evaluated after the initial procedure. Rebleeding occurred in nearly all patients if their inital treatment was a stomal revision, oversewing of varices, or local supportive treatment. The lowest incidence of rebleeding was in the portosystemic shunt group. No patient experienced rebleeding after a shunt for ileostomy or colostomy bleeding. One patient with an ileal conduit rebled for an overall recurrence of 10 percent. Variceal ligation had a 95 percent recurrence rate and stomal revisions a 73 percent recurrence rate when performed as the initial surgical procedure (Table 19). In the ileostomy group, the time interval from the initial procedure until the first episode of rebleeding averaged six months after stomal revision and 9 months after variceal ligation. A total of 33 deaths were reported in the articles reviewed. Twenty-one patients had ileostomies, nine had colostomies, and three had ileal conduits. None of the eight patients who had shunting procedures performed as the intial procedure had died at followup of 14, 14, 27, and 84 months, respectively, for the ileostomy patients, 4 and 120 months, respectively, for the colostomy patients, and 18 months for the ileal conduit patient. The time from the last procedure performed until the time of death was evaluated also. Patients with ileostomies lived an average of 2 months after variceal ligation, 15 months after stomal revision, and 50 months after shunting (Table 20). All treatment of bleeding stomal varices is palliative. The most efficacious treatment should stop bleeding without recurrence, have low morbidity, prolong survival, and be cost effective. Based on these criteria, early portosystemic shunting appears to be the best treatment for bleeding stomal varices. It offers the lowest rates of rebleeding and need
for further surgery, the longest survival, and the lowest risk of encephalopathy. Shunting is associated with fewer hospitalizations, fewer procedures, and fewer transfusions than other procedures and thus is the most cost-effective option available. Portosystemic shunting, however, should be restricted to those patients who can tolerate major surgery and who have a reasonable life expectancy. Suture ligation or sclerotherapy should be employed in patients with end-stage disease, with stomal revision used in all other patients.
References 1. Hesterberg R, Stahlknecht CD, Roher HD. Sclerotherapy for massive enterostomy bleeding resulting from portal hypertension. Dis Colon Rectum 1986;29:275-7. 2. Grundfest-Broniatowski S, Fazio V. Conservative treatment of bleeding stomal varices. Arch Surg 1983;118:981-5. 3. Cameron AD, Fone DJ. Portal hypertension and bleeding ileal varices after colectomy and ileostomy for chronic ulcerative colitis. Gut 1970;11:755-9. 4. Eade MN, Williams JA, Cooke UT. Bleeding from an ileostomy caput medusae. Lancet 1969;2:1166-8. 5. Peck J J, Boyden AM. Exigent ileostomy hemorrhage. Am J Surg 1985;150:153-8. 6. Cooper MJ, Mackie CR, Dhorajiwala J, Baker AL, Moose RA. Hemorrhage from ileal varices after total proctocolectomy. Am J Surg 1981;141:178-9. 7. Ricci RL, Leek R, Greenberger NJ. Chronic gastrointestinal bleeding from ileal varices after total proctocolectomy for ulcerative colitis: correction by mesocaval shunt. Gastroenterology 1980;78:1053-8. 8. Adson MA, Fulton RE. The ileal stoma and portal hypertension. Arch Surg 1977;112:501-4. 9. Graeber GM, Ramer MH, Ackerman NB. Massive hemorrhage from ileostomy and colostomy stomas due to mucocutaneous varices in patients with coexisting cirrhosis. Surgery 1976;79:10710. 10. Foulke J, Wallace DM. Hemorrhage from stomal varices in an ileal conduit. Br J Urol 1975;47:630. 11. Beck DE, Fazio VW, Grundfest-Broniatowski S. Surgical management of bleeding stomal varices. Dis Colon Rectum 1988;31:343-6. 12. Wang MM, McGrew W, Dunn GD. Variceal bleeding from an ileostomy stoma. South Med J 1985;78:733-7. 13. Goldstein WZ, Edoga J, Crystal R. Management of colostomal hemorrhage resulting from portal hypertension. Dis Colon Rectum 1980;23:86-90. 14. Ackerman MB, Graeber GM, Frey J. Enterostomal varices secondary to portal hypertension. Arch Surg 1980;115:1454-5. 15. Morgan TR, Feldshon SD, Tripp MR. Recurrent stomal bleeding: successful treatment using injection sclerotherapy. Dis Colon Rectum 1986;29:269-70. 16. Chapman ML, Janowitz HD. Chronic portal systemic encephalopathy after ileostomy a n d colonic resection. Lancet 1966;2:1064-5. 17. Bloor K, Orr W. A case of hemorrhage from varices in the small intestine due to portal hypertension. Br J Surg 1961;48:4234. 18. Reznick RH, Ishihara A, Chalmers TC, Schimmel, Boston InterHospital Liver Group. A controlled trial of colon bypass in chronic hepatic encephalopathy. Gastroenterology 1968;54:1057-69. 19. Crooks RR, Hensle TW, Heney NM, Wahman A, Irwin RJ. Ileal conduit hemorrhage secondary to portal hypertension. Urology 1978; 12:689-93. 20. Firlit RS, Firlit CF, Canning J. Exsanguinating hemorrhage from
314
21. 22. 23. 24. 25.
26. 27. 28.
CONTE, ET AL.
urinary ileal conduit in patient with portal hypertension. Urology 1978;12:710-11. Perrault JP, Laroze M, Faucher R, et al. Hemorrhage d'un conduit ileal secondaire a une hypertension portale. J Urol (Paris) 1982;88:47-9. Lebrec D, Benhamou J-P. Ectopic varices in portal hypertension clinics. Gastroenterology 1985;14:105-21. Federle M, Clark RA. Mesenteric varices: a source of mesosystemic shunts and gastrointestinal hemorrhage. Gastrointest Radiol 1979;4:331-7. Johnson AG, Simms JM. Correspondence. Br J Surg 1983;70:187. Falchuk KR, Aiello MR, Trey C, Costello P. Recurrent bleeding from ileal varices associated with intraabdominal adhesions: case report and review of the literature. Am J Gastroenterol 1982;77:859-60. Hollands JM. Parastomal hemorrhage from an ileal conduit secondary to portal hypertension. Br J Surg 1982;69:675. Eckhauser FE, Sonda LP, Strodel WE, Edgcomb LP, Turcotte JG. Parastomal ileal conduit hemorrhage and portal hypertension. Ann Surg 1980;5:620-4. Finemore RG. Repeated hemorrhage from a terminal colostomy due to mucocutaneous varices with coexisting metastatic rectal adenocarcinoma. Br J Surg 1979;66:806.
Dis. Col. ~ Rect. April 1990
29. Gray RK, Grollman JH. Acute lower GI bleeding secondary to varices of the superior mesenteric venous system. Radiology 1974;111:559-61. 30. Hamlyn AN, Morris JS, Lunzer MR, Puritz H, Dick R. Portal hypertension with varices in unusual sites. Lancet 1974;2:15314. 31. Moncure AC, Waltman AC, Vandersalm TJ, Linton RR, Levine FH, Abbott WM. Gastrointestinal hemorrhage from adhesion related mesenteric varices. Ann Surg 1976;183:24-9. 32. Freed JS, Szuchmacher PH, Bluestone L, Fano A. Massive colonic variceal bleeding secondary to abnormal splenocolic collaterals: report of a case. Dis Colon Rectum 1978;21:126-7. 33. Goldstein MD, Vrandt LD, Bernstein LH. Hemorrhage from ileal varices: a unusual complication after total portocolectomy in a patient with ulcerative colitis and cirrhosis. Am J Gastroenterol 1983;78:351-4. 34. Wiesner RH, Beaver SJ, LaRusso NF. Bleeding peristomal varices: a serious complication of proctocolectomy for chronic ulcerative colitis in patients with primary sclerosing cholangitis. Hepatology 1982;2:699. 35. Watlans RM. Variceal hemorrhage from a colostomy due to portal hypertension secondary to intrahepatic metastases from rectal carcinoma. Br Med J 1981;282:189-90.
