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

Publikationsverlauf

Eingereicht: 22. Januar 2021

Angenommen nach Revision: 09. Mai 2021

Artikel online veröffentlicht:
05. November 2021

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