Bleeding secondary to peristomal varices is a rare but potentially fatal complication of portal hypertension. TIPS is its first-line etiologic treatment in the setting of cirrhosis with portal hypertension. However, TIPS is not always feasible, especially in cases of contraindication or portal trunk occlusion.
A patient of 63-year old male was referred for persistent peristomal variceal bleeding. He had a past history cirrhosis with portal hypertension due to alcohol consumption and more recently, rectal cancer with metachronous liver metastasis. He was treated by proctectomy with placement of a stoma in the left flank. An evaluation CT scan showed a tumour-like occlusion of the portal vein, the origin of which is uncertain.
He was regularly referred to the emergency department for peristomal bleeding with anaemia, without haemodynamic instability. CT-scan angiogram confirmed ectopic peristomal varices without active bleeding. After multidisciplinary meeting, a minimal invasive approach was decided. Under local anaesthesia and ultrasoung guidance, the varicose vein was punctured by direct percutaneous access using a 22G-needle, and embolized using a mixture of N-Butyl-Cyanoacrylate and Lipiodol. The patient had no complication, and no recurrent bleeding occurred after more than 6 months of follow-up. He was discharged from the hospital 8 days later.
The percutaneous approach is a simple and effective technique. This approach should be the first line treatment when TIPS is not indicated.