UNCOMMON  PRESENTATION  OF  AN  OCCULT  GI  BLEED  

 Resident(s):  Veena  R.  Iyer,  MBBS    

Attending(s):  Jessica  Kuehn-­‐Hajder,  MD,  Donna  D’Souza,  MD,  Olga  L.  Duran-­‐Castro,  MD  

Program/Dept(s):  University  of  Minnesota  

CHIEF  COMPLAINT  &  HPI  

   History  of  Present  Illness     A  76-­‐year-­‐old  woman  presented  with  painless  bleeding  from  an  ileostomy  placed  more  than  15-­‐years  ago.  She  had  a  3-­‐day  history  of  intermittent  daily  bleeding  of  maroon  blood  and  clots  from  the  ileostomy.    She  was  hypotensive,  tachycardiac  and  had  acute  blood  loss  anemia  with  hemoglobin  dropping  from  10.4  g/dl  to  7.7  g/dl,  during  her  hospital  stay.  

   Over  the  next  2  weeks,  she  underwent  an  extensive  work-­‐up  to  identify  the  source  of  bleeding,  which  included  two  Tc-­‐99m  RBC  scans,  two  ileoscopies,  two  video  capsule  endoscopies,  and  selective  transcatheter  arteriography.    None  of  these  investigations  revealed  a  source  of  the  bleeding.  Finally,  a  CTA  of  the  abdomen  with  arterial,  venous  and  delayed  phases  was  performed.    

RELEVANT  HISTORY  

   Past  Medical  History     Crohn’s  disease     Obesity     Cirrhosis,  presumed  secondary  to  non-­‐alcoholic  steatohepatitis     Diabetes  mellitus,  type  2     Asthma  

   Past  Surgical  History     Colectomy  and  end  ileostomy  to  treat  Crohn’s  disease  about  40  years  ago.  

   Drugs     No  use  of  illicit  drugs  or  alcohol  

   Allergies      Aspirin,  Sulfa  drugs,  Levaquin  

 

DIAGNOSTIC  WORKUP  –  NON  INVASIVE  IMAGING  

Longitudinal  right  upper  quadrant  US  shows  a  shrunken  and  nodular  cirrhotic  liver  

Color  Doppler  US  image  of  a  subcutaneous  dilated  vessel  immediately  under  the  stoma  

DIAGNOSTIC  WORKUP  –  CTA  

Figure  A:  Dilated  subcutaneous  vessel(dotted  arrow)  just  under  the  stoma  of  the  ileostomy  (arrow).  Figure  B:  Maximum  intensity  projection  oblique  sagittal  reformatted  image  shows  the  vessel  to  be  a  portosystemic  collateral  and  a  tributary  of  the  portal  vein  (asterix)  

DIAGNOSIS  

   Stomal  (ectopic)  varices,  likely  cause  of  bleeding.  

QUESTION  

  What  is  the  most  likely  cause  for  stomal  bleeding  of  bright  red  blood  in  this  patient,  as  shown  on  the  images?  (click  on  one  of  the  following  answers)  

   A.  Bowel  hernia  B.  Bowel  obstruction  C.  Mucosal  ulceration  D.  Stomal  varices  E.  Arteriovenous  malformation  

CORRECT!  

  What  is  the  most  likely  cause  for  stomal  bleeding  of  bright  red  blood  in  this  patient,  as  shown  on  the  images?  (click  on  one  of  the  following  answers)  

   A.  Bowel  hernia  B.  Bowel  obstruction  C.  Mucosal  ulceration  D.  Stomal  varices  E.  Arteriovenous  malformation  

CONTINUE  WITH  CASE  

SORRY,  THAT’S  INCORRECT.  

  What  is  the  most  likely  cause  for  stomal  bleeding  of  bright  red  blood  in  this  patient,  as  shown  on  the  images?  (click  on  one  of  the  following  answers)  

   A.  Bowel  hernia  B.  Bowel  obstruction  C.  Mucosal  ulceration  D.  Stomal  varices  E.  Arteriovenous  malformation  

CONTINUE  WITH  CASE  

INTERVENTION    

Figure  A:  The  peristomal  varix  was  cannulated  with  a  21-­‐gauge  Jelco  needle  and  contrast  was  injected  to  confirm  position.    Figure  B:  Sclerotherapy  performed  with  3%  sodium  tetradecyl  sulfate  (STS)  foam  injected  under  fluoroscopy.  No  back  bleeding  was  observed  through  a  second  cannula  in  the  varix,  suggesting  occlusion  of  the  varix.  

A   B  

FOLLOW-­‐UP  

•  Injection  of  the  sclerosant  successfully  treated  the  bleeding  stomal  varices.  

•  At  6-­‐month  follow-­‐up,  the  patient  did  not  have  any  further  episodes  of  major  GI  or  stoma  bleeding.  

•  The  patient  did  well  for  14  months,  at  which  time  she  presented  with  bleeding  from  the  ileostomy,  and  percutaneous  sclerotherapy  of  the  varices  with  STS  again  successfully  stopped  bleeding  

SUMMARY  &  TEACHING  POINTS  

•  In  summary,  the  patient  presented  with  active  stomal  bleeding.  She  underwent  two  Tc-­‐99m  RBC  scans,  two  ileoscopies,  two  video  capsule  endoscopies,  and  selective  transcatheter  arteriography  without  localization  of  a  source  of  bleeding.  She  was  intermittently  transfused  packed  RBCs  for  active  bleeding  and  hemoglobin  drop  to  <8  g/dl.    

•  CTA  of  the  abdomen  revealed  peristomal  varices,  which  were  thought  to  be  source  of  the  bleeding.  These  were  successfully  treated  with  sclerotherapy  under  ultrasound  and  fluoroscopic  guidance.  

•  Temporary  hemostasis  is  the  immediate  goal  of  therapy,  and  can  be  achieved  with  local  pressure,  placing  the  patient  in  a  recumbent  position,  cautery  with  silver  nitrate  or  local  suturing.  Sclerotherapy  and  percutaneous  embolization  of  the  varices  are  additional  options  for  management  after  initial  stabilization  of  the  bleed.  As  in  the  case  of  patients  with  bleeding  esophageal  varices,  pharmacological  management  including  octreotide  and  nonselective  beta-­‐blockers  should  be  initiated.  Decompressive  treatment  options  such  as  transjugular  intrahepatic  portosystemic  shunting,  portacaval  shunting  or  liver  transplantation  should  be  considered  on  a  case-­‐by-­‐case  basis.  Additionally,  surgical  options  to  reduce  the  risk  of  rebleeding  may  include  re-­‐siting  of  the  stoma  and  disconnection  of  mucocutaneous  portosystemic  communications.  

QUESTION  

  What  is  the  best  first  diagnostic  test  in  a  patient  presenting  with  bleeding  stomal  varices?  

   A.  CT  abdomen  B.  CT  angiography  C.  Bleeding  scan  D.  Ultrasound  

CORRECT!  

  What  is  the  best  first  diagnostic  test  in  a  patient  presenting  with  bleeding  stomal  varices?  

   A.  CT  abdomen  B.  CT  angiography  C.  Bleeding  scan  D.  Ultrasound  -­‐  Doppler  ultrasound  of  the  liver  and  portal  venous  system,  with  

grayscale  and  Doppler  peristomal  images.  

CONTINUE  WITH  CASE  

SORRY,  THAT’S  INCORRECT.  

  What  is  the  best  first  diagnostic  test  in  a  patient  presenting  with  bleeding  stomal  varices?  

   A.  CT  abdomen  B.  CT  angiography  C.  Bleeding  scan  D.  Ultrasound  -­‐  Doppler  ultrasound  of  the  liver  and  portal  venous  system,  with  

grayscale  and  Doppler  peristomal  images.  

CONTINUE  WITH  CASE  

REFERENCES  

   Spier  BJ,  Fayyad  AA,  Lucey  MR  et  al.  Bleeding  stomal  varices:  case  series  and  systematic  review  of  the  literature.  Clin  Gastroenterol  Hepatol.  2008;  6:  346–52.    

  Norton  ID,  Andrews  JC,  Kamath  PS.  Management  of  ectopic  varices.  Hepatology.  1998;  28:  1154–8.  

   Saad  WE,  Schwaner  S,  Lippert  A  et  al.  Management  of  stomal  varices  with  transvenous  obliteration  utilizing  sodium  tetradecyl  sulfate  foam  sclerosis.  Cardiovasc  Intervent  Radiol    2014;  37:1625–30.  

   Deipolyi  AR,  Kalva  SP,  Oklu  R,  Walker  TG,  Wicky  S,  Ganguli  S.  Reduction  in  portal  venous  pressure  by  transjugular  intrahepatic  portosystemic  shunt  for  treatment  of  hemorrhagic  stomal  varices.  AJR  Am  J  Roentgenol.  2014;  203:  668–73.