United Health Services, Wilson Medical Center Binghamton, NY
Ahmed Shehadah, MD1, Timothy Chan, BS2, Alshaima Yousef, MD3, Khandokar Talib, MD4, Usama Sakhawat, MD5, Amanke Oranu, MD1, Toseef Javaid, MD5, Ali Marhaba, MD5 1United Health Services, Wilson Medical Center, Binghamton, NY; 2SUNY Upstate Medical University, Syracuse, NY; 3Rochester General Hospital, Rochester, NY; 4United Health Services, Johnson City, NY; 5United Health Services, Wilson Medical Center, Johnson City, NY Introduction: Parastomal variceal bleeding is a challenging clinical entity, especially in patients with multiple comorbidities. Literature suggests that transjugular intrahepatic portosystemic shunt (TIPS) placement can be an effective treatment option in select patients. However, TIPS carries several relative and absolute contraindications, including, severe congestive heart failure, high MELD score, pulmonary hypertension, and valvular disease, which may preclude placement in such highly comorbid patients. We present a case highlighting the diagnostic approach and successful use of TIPS for parastomal variceal bleeding in an elderly patient with multiple significant comorbidities.
Case Description/
Methods: A 74-year-old male with significant comorbidities including rectal adenocarcinoma status post colectomy with right lower quadrant ileostomy, aortic stenosis with valve prosthesis, heart failure with a left ventricular ejection fraction of 45%, gastrointestinal ulcers, arteriovenous malformations, atrial fibrillation on anticoagulation, mild pulmonary hypertension, and liver cirrhosis. Over the course of one year, he was hospitalized seven times with progressive weakness and hypotension in the setting of intermittent stoma site bleeding, often requiring multiple blood transfusions.
Video capsule endoscopy and several upper and lower endoscopic procedures were performed, including trans-stomal ileoscopy; failed to identify the source of bleeding. Parastomal varices were later confirmed via ileostomal endoscopic ultrasound and a triple-phase liver computed tomography scan.
Management with suture ligation, topical silver nitrate, argon plasma coagulation, beta blockers, and octreotide proved insufficient. Despite the patient’s high risk profile, including a MELD score of 20, a multidisciplinary decision was made to proceed with TIPS, which the patient tolerated well and resolved further stoma site bleeding. Patient had no complications from TIPS placement and bleeding resolved to date. Discussion: This case illustrates the diagnostic and therapeutic challenges of managing parastomal variceal bleeding in a medically complex patient and highlights the importance of multidisciplinary involvement in the evaluation of TIPS placement. Despite his high-risk profile, TIPS was the only intervention that provided sustained control of his variceal bleeding. TIPS may offer better outcomes than conservative approaches in similarly complex select cases and further studies are needed to support this claim.
Figure: Image 1: EUS examination of the neo-terminal ileum/ stoma showing anechoic, tubular, and serpiginous structure with demonstration of flow with color doppler suggestive of a medium-sized parastomal varix. Few collaterals were also observed in the area.
Figure: Image 2: CT abdomen triple phase - Right lower quadrant ostomy with dilated and enlarged serpiginous vascular structures noted within the stoma with contrast opacified on the venous phase images, likely representing peristomal varices.
Disclosures: Ahmed Shehadah indicated no relevant financial relationships. Timothy Chan indicated no relevant financial relationships. Alshaima Yousef indicated no relevant financial relationships. Khandokar Talib indicated no relevant financial relationships. Usama Sakhawat indicated no relevant financial relationships. Amanke Oranu indicated no relevant financial relationships. Toseef Javaid indicated no relevant financial relationships. Ali Marhaba indicated no relevant financial relationships.
Ahmed Shehadah, MD1, Timothy Chan, BS2, Alshaima Yousef, MD3, Khandokar Talib, MD4, Usama Sakhawat, MD5, Amanke Oranu, MD1, Toseef Javaid, MD5, Ali Marhaba, MD5. P5285 - Parastomal Varices: When Bleeding Demands a Shunt, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
