Iyer final.pptx

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 herniaB. Bowel obstructionC. Mucosal ulcerationD. Stomal varicesE. Arteriovenous malformation

CORRECT!



CONTINUE WITH CASE

SORRY, THAT’S INCORRECT.



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 abdomenB. CT angiographyC. Bleeding scanD. Ultrasound

CORRECT!


A. CT abdomenB. CT angiographyC. Bleeding scanD. Ultrasound - Doppler ultrasound of the liver and portal venous

system, with grayscale and Doppler peristomal images.

CONTINUE WITH CASE

SORRY, THAT’S INCORRECT.


A. CT abdomenB. CT angiographyC. Bleeding scanD. 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.

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Iyer final.pptx