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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, MDProgram/Dept(s): University of Minnesota

Chief Complaint & HPIHistory of Present IllnessA 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 HistoryPast Medical HistoryCrohns diseaseObesityCirrhosis, presumed secondary to non-alcoholic steatohepatitisDiabetes mellitus, type 2AsthmaPast Surgical HistoryColectomy and end ileostomy to treat Crohns disease about 40 years ago.DrugsNo use of illicit drugs or alcoholAllergies Aspirin, Sulfa drugs, Levaquin

Diagnostic Workup Non invasive imagingLongitudinal right upper quadrant US shows a shrunken and nodular cirrhotic liverColor Doppler US image of a subcutaneous dilated vessel immediately under the stoma

Diagnostic Workup CTAFigure 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)

DiagnosisStomal (ectopic) varices, likely cause of bleeding.

QuestionWhat 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) Bowel herniaBowel obstructionMucosal ulcerationStomal varicesArteriovenous 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) Bowel herniaBowel obstructionMucosal ulcerationStomal varicesArteriovenous 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) Bowel herniaBowel obstructionMucosal ulcerationStomal varicesArteriovenous 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.

AB

Follow-upInjection 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 PointsIn 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