Skip to main content

Advertisement

SpringerLink
Log in

Management of parastomal varices: who re-bleeds and who does not? A systematic review of the literature

  • Review
  • Published:
Techniques in Coloproctology Aims and scope Submit manuscript

Abstract

Although first described almost half a century ago, parastomal varices are not easily recognised as a cause of stomal bleeding even though they occur in up to 5 % of all people who have a stoma. The main challenges associated with this condition are diagnosis and management. For that reason, the aim of the present study was to perform a systematic review of all the available literature pertaining to this topic. The primary end point was recurrent variceal haemorrhage after a particular mode of management. Several secondary endpoints focused on means of diagnosis and pathological conditions of abdominal organs that could contribute to both the formation of these varices and the rate of re-bleeding. Sixty-six articles comprising 210 patients were analysed. Parastomal varices tend to be more frequent in men manifesting with bleeding in the fifth decade of life. The majority (72.0 %) of patients who bleed from parastomal varices do so from an ileostomy. The most common pathology leading to stoma formation is ulcerative colitis (57.8 %). Liver cirrhosis is the most common cause of portal hypertension leading to the development of parastomal varices and primary sclerosing cholangitis is in second place. A third of patients with parastomal varices also have co-existent oesophageal varices. There are no pathognomonic symptoms or signs of parastomal varices and only the minority of patients have a raspberry appearance of the stoma, visibly dilated submucosal veins and bluish discoloration and hyperkeratosis of the skin around it. Venous phase contrast angiography or portal venography is the most successful radiological investigation to confirm the diagnosis. The transjugular intrahepatic portosystemic shunt (TIPS) procedure has the highest success rate in preventing recurrent haemorrhage and local measures, either non-operative or surgical, are the least effective. Comparison of TIPS with non-operative and local surgical treatment groups produced a risk reduction in 4.60 and 3.85, respectively. Treatment of 1.37 people with a TIPS procedure prevents one person suffering from recurrent variceal bleeding and using TIPS can reduce the likelihood of re-bleeding by 78.5 %. Surgical portosystemic shunting or embolisation alone leaves patients with approximately 50 % chance of re-bleeding. Although TIPS has gained popularity over the last two decades almost three quarters of patients with parastomal varices are still treated with local measures as first-line management. Liver transplantation as a treatment of the primary cause of parastomal varices remains very rare.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Eckhauser FE, Sonda P, Strodel WE, Edgcomb LP, Turcotte JG (1980) Parastomal ileal conduit hemorrhage and portal hypertension. Ann Surg 192:620–624

    PubMed  CAS  Google Scholar 

  2. Eade MN, Williams JA, Cooke WT (1969) Bleeding from an ileostomy caput medusae. Lancet 2:1166–1168

    Article  PubMed  CAS  Google Scholar 

  3. Thompson J (1993) Caput medusae: peristomal varices. J ET Nurs 20:216–219

    PubMed  CAS  Google Scholar 

  4. Resnick RH, Ishihara A, Chalmers TC, Schimmel EM (1968) A controlled trial of colon bypass in chronic hepatic encephalopathy. Gastroenterology 54:1057–1069

    PubMed  CAS  Google Scholar 

  5. Foulkes J, Wallace DM (1975) Haemorrhage from stomal varices in an ileal conduit. Br J Urol 47:630

    Article  PubMed  CAS  Google Scholar 

  6. Firlit RS, Firlit CF, Canning J (1978) Exsanguinating haemorrhage from urinary ileal conduit in patient with portal hypertension. Urology 12:710–711

    Article  PubMed  CAS  Google Scholar 

  7. Scaletscky R, Wright JK Jr, Shaw J, Smith JA Jr (1994) Ileal conduit venous varices for portal hypertension as a cause of recurrent, massive hemorrhage: case report and review of the literature. J Urol 151:417–419

    PubMed  CAS  Google Scholar 

  8. Lo RK, Johnson DE, Smith DB (1984) Massive bleeding from an ileal conduit caput medusae. J Urol 131:114–115

    PubMed  CAS  Google Scholar 

  9. Kabeer MA, Jackson L, Widdison AL, Maskell G, Mathew J (2007) Stomal varices: a rare cause of stomal hemorrhage. A report of three cases. Ostomy Wound Manage 53:20–22

    PubMed  Google Scholar 

  10. Wang MM, McGrew W, Dunn GD (1985) Variceal bleeding from an ileostomy stoma. South Med J 78:733–737

    Article  PubMed  CAS  Google Scholar 

  11. Watkins RM (1981) Variceal haemorrhage from a colostomy due to portal hypertension secondary to intrahepatic metastases from rectal carcinoma. Br Med J 282:189–190

    Article  CAS  Google Scholar 

  12. Finemore RG (1979) Repeated haemorrhage from a terminal colostomy due to mucocutaneous varices with coexisting hepatic metastatic rectal adenocarcinoma: a case report. Br J Surg 66:806

    Article  PubMed  CAS  Google Scholar 

  13. Nunes J, Alexandrino P, Marinho RT (2009) Stomal varices: a rare cause of severe bleeding in portal hypertension. J Gastrointestin Liver Dis 18:500

    PubMed  Google Scholar 

  14. Chavez DR, Snyder PM, Juravsky LI, Heaney JA (1994) Recurrent ileal conduit hemorrhage in an elderly cirrhotic man. J Urol 152:951–953

    PubMed  CAS  Google Scholar 

  15. de Hoog J, Yong TL, Yellapu S (2010) Novel surgical control of bleeding para-stomal varices. ANZ J Surg 80:469–470

    Article  PubMed  Google Scholar 

  16. Conte JV, Arcomano TA, Naficy MA, Holt RW (1990) Treatment of bleeding stomal varices. Report of a case and review of the literature. Dis Colon Rectum 33:308–314

    Article  PubMed  CAS  Google Scholar 

  17. Spier BJ, Fayyad AA, Lucey MR et al (2008) Bleeding stomal varices: case series and systematic review of the literature. Clin Gastroenterol Hepatol 6:346–352

    Article  PubMed  Google Scholar 

  18. Lebrec D, Benhamou JP (1985) Ectopic varices in portal hypertension. Clin Gastroenterol 14:105–121

    PubMed  CAS  Google Scholar 

  19. Norton ID, Andrews JC, Kamath PS (1998) Management of ectopic varices. Hepatology 28:1154–1158

    Article  PubMed  CAS  Google Scholar 

  20. Helmy A, Al Kahtani K, Al Fadda M (2008) Updates in the pathogenesis, diagnosis and management of ectopic varices. Hepatol Int 2:322–334

    Article  PubMed  Google Scholar 

  21. Weisner RH, LaRusso NF, Dozois RR, Beaver SJ (1986) Peristomal varices after proctocolectomy in patients with primary sclerosing cholangitis. Gastroenterology 90:316–322

    Google Scholar 

  22. Peck JJ, Boyden AM (1985) Exigent ileostomy hemorrhage. A complication of proctocolectomy in patients with chronic ulcerative colitis and primary sclerosing cholangitis. Am J Surg 150:153–158

    Article  PubMed  CAS  Google Scholar 

  23. Fucini C, Wolff BG, Dozois RR (1991) Bleeding from peristomal varices: perspectives on prevention and treatment. Dis Colon Rectum 34:1073–1078

    Article  PubMed  CAS  Google Scholar 

  24. Hamlyn AN, Morris JS, Lunzer MR, Puritz H, Dick R (1974) Portal hypertension with varices in unusual sites. Lancet 2:1531–1534

    Article  PubMed  CAS  Google Scholar 

  25. Choi WJ, Lee CH, Kim KA, Park CM, Kim JY (2006) Ectopic varices in colonic stoma: MDCT findings. Korean J Radiol 7:297–299

    Article  PubMed  Google Scholar 

  26. Goldstein WZ, Edoga J, Crystal R (1979) Management of colostomal hemorrhage resulting from portal hypertension. Dis Colon Rectum 23:86–90

    Article  Google Scholar 

  27. Ahari HK, Feldman L, Kaufman JA, Gianturco LE (1999) Vascular and interventional case of the day. Peristomal varices. AJR Am J Roentgenol 173:831–832

    Article  Google Scholar 

  28. Ackerman NB, Graeber GM, Fey J (1980) Enterostomal varices secondary to portal hypertension: progression of disease in conservatively managed cases. Arch Surg 115:1454–1455

    Article  PubMed  CAS  Google Scholar 

  29. Goldstein MB, Brandt LJ, Bernstein LH, Sprayragen S (1983) Hemorrhage from ileal varices: a delayed complication after total proctocolectomy in a patient with ulcerative colitis and cirrhosis. Am J Gastroenterol 78:351–354

    PubMed  CAS  Google Scholar 

  30. Handschin AE, Weber M, Weishaupt D, Fried M, Clavien PA (2002) Contrast-enhanced three-dimensional magnetic resonance angiography for visualization of ectopic varices. Dis Colon Rectum 45:1541–1544

    Article  PubMed  Google Scholar 

  31. Graeber GM, Ratner MH, Ackerman NB (1976) Massive hemorrhage from ileostomy and colostomy stomas due to mucocutaneous varices in patients with coexisting cirrhosis. Surgery 79:107–110

    PubMed  CAS  Google Scholar 

  32. Roberts PL, Martin FM, Schoetz DJ Jr, Murray JJ, Coller JA, Veidenheimer MC (1990) Bleeding stomal varices. The role of local treatment. Dis Colon Rectum 33:547–549

    Article  PubMed  CAS  Google Scholar 

  33. Noubibou M, Douala HC, Druez PM, Kartheuzer AH, Detry RJ, Geubel AP (2006) Chronic stomal variceal bleeding after colonic surgery in patients with portal hypertension: efficacy of beta-blocking agents? Eur J Gastroenterol Hepatol 18:807–808

    Article  PubMed  CAS  Google Scholar 

  34. Chong VH, Tan KK, Sharif F (2008) Successful treatment of parastomal varices bleeding with percutaneous N-butyl-2-cyanoacrylate glue injection. Surg Laparosc Endosc Percutan Tech 18:520–522

    Article  PubMed  Google Scholar 

  35. Minami S, Okada K, Matsuo M, Kamohara Y, Sakamoto I, Kanematsu T (2007) Treatment of bleeding stomal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol 42:91–95

    Article  PubMed  Google Scholar 

  36. Thouveny F, Aube C, Konate A, Lebigot J, Bouvier A, Oberti F (2008) Direct percutaneous approach for endoluminal glue embolization of stomal varices. J Vasc Interv Radiol 19:774–777

    Article  PubMed  Google Scholar 

  37. Hesterberg R, Stahlknecht CD, Roher HD (1986) Sclerotherapy for massive enterostomy bleeding resulting from portal hypertension. Dis Colon Rectum 29:275–277

    Article  PubMed  CAS  Google Scholar 

  38. Morgan TR, Feldshon SD, Tripp MR (1986) Recurrent stomal variceal bleeding. Successful treatment using injection sclerotherapy. Dis Colon Rectum 29:269–270

    Article  PubMed  CAS  Google Scholar 

  39. Beck DE, Fazio VW, Grundfest-Broniatowski S (1988) Surgical management of bleeding stomal varices. Dis Colon Rectum 31:343–346

    Article  PubMed  CAS  Google Scholar 

  40. Adson MD, Fulton RE (1977) The ileal stoma and portal hypertension: an uncommon site of variceal bleeding. Arch Surg 112:501–504

    Article  PubMed  CAS  Google Scholar 

  41. Crooks KK, Hensle TW, Heney NM, Waltman A, Irwin RJ Jr (1978) Ileal conduit hemorrhage secondary to portal hypertension. Urology 12:689–693

    Article  PubMed  CAS  Google Scholar 

  42. Cameron AD, Fone DJ (1970) Portal hypertension and bleeding ileal varices after colectomy and ieostomy for chronic ulcerative colitis. Gut 11:755–759

    Article  PubMed  CAS  Google Scholar 

  43. Ricci RL, Lee KR, Greenberger NJ (1980) Chronic gastrointestinal bleeding from ileal varices after total proctocolectomy for ulcerative colitis: correction by mesocaval shunt. Gastroenterology 78:1053–1058

    PubMed  CAS  Google Scholar 

  44. Grundfest-Broniatowski S, Fazio V (1983) Conservative treatment of bleeding stomal varices. Arch Surg 118:981–985

    Article  PubMed  CAS  Google Scholar 

  45. Kartheuser AH, Dozois RR, Weisner RH, LaRusso NF, Ilstrup DM, Schleck CD (1993) Complications and risk factors after ileal pouch-anal anastomosis for ulcerative colitis associated with primary sclerosing cholangitis. Ann Surg 217:314–320

    Article  PubMed  CAS  Google Scholar 

  46. Samaraweera RN, Feldman L, Widrich WC et al (1989) Stomal varices: percutaneous transhepatic embolization. Radiology 170:779–782

    PubMed  CAS  Google Scholar 

  47. Kishimoto K, Hara A, Arita T et al (1999) Stomal varices: treatment by percutaneous transhepatic coil embolization. Cardiovasc Intervent Radiol 22:523–525

    Article  PubMed  CAS  Google Scholar 

  48. Naidu SG, Castle EP, Kriegshauser JS, Huettl EA (2010) Direct percutaneous embolization of bleeding stomal varices. Cardiovasc Intervent Radiol 33:201–204

    Article  PubMed  Google Scholar 

  49. Lashley DB, Saxon RR, Fuchs EF, Chin DH, Lowe BA (1997) Bleeding ileal conduit stomal varices: diagnosis and management using transjugular transhepatic angiography and embolization. Urology 50:612–614

    Article  PubMed  CAS  Google Scholar 

  50. Macedo TA, Andrews JC, Kamath PS (2005) Ectopic varices in the gastrointestinal tract: short- and long-term outcomes of percutaneous therapy. Cardiovasc Intervent Radiol 28:178–184

    Article  PubMed  Google Scholar 

  51. Toumeh KK, Girardot JD, Choo IW, Andrews JC, Cho KJ (1995) Percutaneous transhepatic embolization as treatment for bleeding ileostomy varices. Cardiovasc Intervent Radiol 18:179–182

    Article  PubMed  CAS  Google Scholar 

  52. Shibata D, Brophy DP, Gordon FD, Anastopoulos HT, Sentovich SM, Bleday R (1999) Transjugular intrahepatic portosystemic shunt for treatment of bleeding ectopic varices with portal hypertension. Dis Colon Rectum 42:1581–1585

    Article  PubMed  CAS  Google Scholar 

  53. Johnson PA, Laurin J (1997) Transjugular portosystemic shunt for treatment of bleeding stomal varices. Dig Dis Sci 42:440–442

    Article  PubMed  CAS  Google Scholar 

  54. Wong RC, Berg CL (1997) Portal hypertensive stomapathy: a newly described entity and its successful treatment by placement of a transjugular intrahepatic portosystemic shunt. Am J Gastroenterol 92:1056–1057

    PubMed  CAS  Google Scholar 

  55. Alkari B, Shaath NM, El-Dhuwaib Y (2005) Transjugular intrahepatic porto-systemic shunt and variceal embolisation in the management of bleeding stomal varices. Int J Colorectal Dis 20:457–462

    Article  PubMed  Google Scholar 

  56. Carrafiello G, Laganà D, Giorgianni A et al (2007) Bleeding from peristomal varices in a cirrhotic patient with ileal conduit: treatment with transjugular intrahepatic portocaval shunt (TIPS). Emerg Radiol 13:341–343

    Article  PubMed  Google Scholar 

  57. Han SG, Han KJ, Cho HG et al (2007) A case of successful treatment of stomal variceal bleeding with transjugular intrahepatic portosystemic shunt and coil embolization. J Korean Med Sci 22:583–587

    Article  PubMed  Google Scholar 

  58. Farquharson AL, Bannister JJ, Yates SP (2006) Peristomal varices—life threatening or luminal? Ann R Coll Surg Engl 88:W6–W8

    Article  PubMed  CAS  Google Scholar 

  59. Kochar N, Tripathi D, McAvoy NC, Ireland H, Redhead DN, Hayes PC (2008) Bleeding ectopic varices in cirrhosis: the role of transjugular intrahepatic portosystemic stent shunts. Aliment Pharmacol Ther 28:294–303

    Article  PubMed  CAS  Google Scholar 

  60. Nayar M, Saravanan R, Rowlands PC et al (2006) TIPSS in the treatment of ectopic variceal bleeding. Hepatogastroenterology 53:584–587

    PubMed  CAS  Google Scholar 

  61. Morris CS, Najarian KE (2000) Transjugular intrahepatic portosystemic shunt for bleeding stomal varices associated with chronic portal vein occlusion: long term angiographic, hemodynamic and clinical follow up. Am J Gastroenterol 95:2966–2968

    Article  PubMed  CAS  Google Scholar 

  62. Ryu RK, Nemcek AA, Chrisman HB et al (2000) Treatment of stomal variceal hemorrhage with TIPS: case report and review of the literature. Cardiovasc Intervent Radiol 23:301–303

    Article  PubMed  CAS  Google Scholar 

  63. Vangeli M, Patch D, Terreni N et al (2004) Bleeding ectopic varices—treatment with transjugular intrahepatic porto-systemic shunt (TIPS) and embolisation. J Hepatol 41:560–566

    Article  PubMed  Google Scholar 

  64. Vidal V, Joly L, Perreault P, Bouchard L, Lafortune M, Pomier-Layrargues G (2006) Usefulness of transjugular intrahepatic portosystemic shunt in the management of bleeding ectopic varices in cirrhotic patients. Cardiovasc Intervent Radiol 29:216–219

    Article  PubMed  CAS  Google Scholar 

  65. Arulraj R, Mangat KS, Tripathi D (2011) Embolization of bleeding stomal varices by direct percutaneous approach. Cardiovasc Intervent Radiol 2:S210–S213

    Article  Google Scholar 

  66. Wolfsen HC, Kozarek RA, Bredfeldt JE, Fenster LF, Brubacher LL (1990) The role of endoscopic injection sclerotherapy in the management of bleeding peristomal varices. Gastrointest Endosc 36:472–474

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

We are grateful to Dr. Katharine Thomson for her help with selection and initial review of articles. Special thanks to Elizabeth Wiredu, Medical Statistician, NVivo Trainer and Consultant, Higher Education Academy Fellow, Data Solutions Services, Rufford, Lancashire, UK, for advising us on statistical methodology and for carrying out statistical analysis.

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Department of Surgery, Southport and Ormskirk Hospital, Town Lane, Southport, Merseyside, PR8 6PN, UK

    M. O. Pennick & D. Y. Artioukh

Authors
  1. M. O. Pennick
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. D. Y. Artioukh
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to D. Y. Artioukh.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Pennick, M.O., Artioukh, D.Y. Management of parastomal varices: who re-bleeds and who does not? A systematic review of the literature. Tech Coloproctol 17, 163–170 (2013). https://doi.org/10.1007/s10151-012-0922-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10151-012-0922-6

Keywords

Search

Navigation