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UNCOMMON

PRESENTATION OF AN
OCCULT GI BLEED

Resident(s): Veena R. Iyer, MBBS

Attending(s): Jessica Kuehn-Hajder, MD, Donna DSouza, 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

Crohns disease
Obesity
Cirrhosis, presumed secondary to non-alcoholic steatohepatitis
Diabetes mellitus, type 2
Asthma

Past Surgical History

Colectomy and end ileostomy to treat Crohns 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.
B.
C.
D.
E.

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

Bowel hernia
Bowel obstruction
Mucosal ulceration
Stomal varices
Arteriovenous malformation

CONTINUE WITH CASE

SORRY, THATS 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.
B.
C.
D.
E.

Bowel hernia
Bowel obstruction
Mucosal ulceration
Stomal varices
Arteriovenous malformation

CONTINUE WITH CASE

INTERVENTION
A

Figure A: The peristomal varix was cannulated with a 21-gauge Jelco needle and contrast was injected to conrm position.

Figure B: Sclerotherapy performed with 3% sodium tetradecyl sulfate (STS) foam injected under uoroscopy. No back
bleeding was observed through a second cannula in the varix, suggesting occlusion of the varix.

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 uoroscopic 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 rst diagnostic test in a patient presenting with bleeding
stomal varices?

A.
B.
C.
D.

CT abdomen
CT angiography
Bleeding scan
Ultrasound

CORRECT!
What is the best rst diagnostic test in a patient presenting with bleeding
stomal varices?

A.
B.
C.
D.

CT abdomen
CT angiography
Bleeding scan
Ultrasound - Doppler ultrasound of the liver and portal venous system, with
grayscale and Doppler peristomal images.

CONTINUE WITH CASE

SORRY, THATS INCORRECT.


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

A.
B.
C.
D.

CT abdomen
CT angiography
Bleeding scan
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: 34652.
Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology.
1998; 28: 11548.
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; 37:162530.
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: 66873.