A novel, minimally invasive technique for management of peristomal varices
Authors: James H. Tabibian, Barham K. Abu Dayyeh, Gregory J. Gores, Michael J. Levy
Journal: Hepatology (2015)

Potential conflict of interest: Nothing to report. To the Editor: Peristomal varices are a common, potentially lethal complication of portal hypertension in patients who have undergone intestinal surgery with formation of an ileostomy or alternatively a urinary ileal conduit (e.g., secondary to a genitourinary tract malignancy).1 Classically, peristomal varices are seen in individuals with primary sclerosing cholangitis (PSC) who have undergone proctocolectomy and ileostomy for inflammatory bowel disease, most often ulcerative colitis, but other clinical presentations have also been recognized.1 In one study, for example, of patients with PSC and ulcerative colitis who had undergone end ileostomy, eight of 31 patients (26%) developed peristomal varices and subsequent bleeding.3 As a result of this complication, among patients with PSC (or those with other risk factors for portal hypertension, e.g., autoimmune hepatitis) who are in need of colectomy, ileal pouch–anal anastomosis is recommended over end ileostomy given bleeding peristomal varices may be life‐threatening and leave little therapeutic recourse2; moreover, current treatment options (e.g., percutaneous transhepatic embolization, transjugular intrahepatic portosystemic shunt, and orthotopic liver transplantation) are invasive, and patients may have contraindications to them.3 Here we present a novel, minimally invasive, and readily applicable method for management of peristomal varices. A 70‐year‐old woman with cirrhotic‐stage PSC and colectomy for ulcerative colitis was referred for management of recurrent peristomal variceal hemorrhage. She had required multiple packed red blood cell transfusions despite somatostatin, nonselective beta‐blockade, and topical silver nitrate. Varices were apparent on magnetic resonance imaging (Fig. 1A) and at the ileostomy site (Fig. 1B). A multidisciplinary decision was made to proceed with endoscopic ultrasound (EUS)–guided therapy. Curvilinear EUS (UC140P‐AL5; Olympus, Center Valley, PA) and power and pulse Doppler identified an extensive network of 5‐mm peristomal varices (Fig. 1C). Six microcoils (MWCE‐18S‐8/4‐Embolization Microcoil; Cook, Bloomington, IN) were injected under EUS and fluoroscopic guidance (Fig. 1D) using a 22‐gauge needle (EUSN‐3; Cook Endoscopy, Winston‐Salem, NC); three of the microcoils were placed without intubating the ileostomy, while the other three were placed from within the ileostomy orifice. Doppler EUS demonstrated cessation of flow with no rebleeding over the subsequent 9 months.Figure 1: Varices apparent on magnetic resonance imaging (A) and at the stomal site (B). Extensive network of 5‐mm peristomal varices seen with curvilinear EUS and power and pulse Doppler permit identification [Correction added on July 28, 2015, after first online publication: the words "permit identification" were added to the end of the previous sentence.]. (C). Six microcoils deployed under EUS and fluoroscopic guidance (D).The technique reported herein represents a durable and less invasive alternative to interventional radiologic or surgical management for difficult‐to‐treat peristomal varices. We believe it can be implemented safely and effectively for patients with this complication in centers with expertise in EUS.