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A) Percutaneous transhepatic portal venography revealed widened portal vein trunk, spleen vein, and IMV. (B) Venography showed a complex network of parastomal variceal vessels arising from the IMV. Communicating veins to systemic circulation can be noticed (arrows). (C) Embolization using Onyx LES (arrows) in combination with coils (arrowheads) via transhepatic approach. IMV\u200A=\u200Ainferior mesenteric vein, LES\u200A=\u200Aliquid embolic system, PV\u200A=\u200Aportal vein trunk, SV\u200A=\u200Aspleen vein.
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Parastomal variceal bleeding is a rare complication of portal hypertension, which often occurs in a recurrent manner and might be life-threatening in extreme situations. Treatment options vary, and no standard therapy has been established.
Herein, we report 2 such cases. The first patient suffered from parastomal variceal bleeding after Hartmann pr...
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... Nonetheless, if bleeding continues, it can lead to serious morbidity, including repeated hospitalizations and blood transfusions [3]. Strategies for managing stomal variceal bleeding include lo-cal compression, balloon-occluded retrograde transvenous obliteration (B-RTO), embolization by direct puncture [4], percutaneous transhepatic obliteration (PTO), transjugular intrahepatic portosystemic shunting (TIPS), or stomal revision and liver transplantation [5]. Here, we report a case of successful PTO for stomal variceal bleeding using a microballoon catheter with systemic drainage vein compression from the body surface. ...
We report a case of successful treatment of stomal variceal bleeding with percutaneous transhepatic obliteration using a microballoon catheter concomitantly with drainage vein compression. A 72-year-old man with alcoholic cirrhosis was admitted to our hospital due to repeated hemorrhage of stomal varices. Percutaneous transhepatic obliteration was then selected for treatment because computed tomography revealed the stomal varices being fed by only two branches of the superior and inferior mesenteric veins. During microballoon inflation, 5% ethanolamine oleate with iopamidol was injected into each branch, and the systemic drainage veins were compressed by the gauze from the body surface near the stoma. No rebleeding from the stomal varices has been observed 14 months after the procedure.
... A case series describes the benefits of Oynx solution in helping with complete embolization of varices and tiny tributaries while utilizing coil embolization more proximally at larger varix to help achieve occlusion. 19 Newer treatments include a recent case by Fergusson, et al. that described a novel use of a hemorrhoid banding device for successful control of PVB. 20 Early recognition of PVB and an understanding of the availability of treatment modalities are imperative as mortality from acute variceal bleed is high. ...
Parastomal variceal bleeding (PVB) is a serious complication occurring in up to 27% of patients with an ostomy and concurrent cirrosis and portal hypertension. The management of PVB is difficult and there are no clear guidelines on this matter. Transjugular intrahepatic portosystemic shunt (TIPS), sclerotherapy, and /or coil embolization are all therapies that have been shown to successfully manage PVB. We present a case series with five different patients who had a PVB at our institution. The aim of this case series is to report our experience on the management of this infrequently reported but serious condition. We also conducted a systemic literatura review focusing on the treatment modalities of 163 patients with parastomal variceal bleeds. In our series, patient 1 had embolization and sclerotherapy without control of bleed and expired on the day of intervention due to hemorrhagic shock. Patient 2 had TIPS in conjunction with embolization and sclerotherapy and had no instance of rebleed 441 days after therapy. Patient 3 did not undergo any intervention due to high risk for morbidity and mortality, the bleed self-resolved and there was no further rebleed, this same patient died of sepsis 73 days later. Patient 4 had embolization and sclerotherapy and had no instance of rebleed 290 days after therapy. Patient 5 had TIPS procedure and was discharged five days post procedure without rebleed, patient has since been lost to follow-up.
... It accounts for 5%-20% of blindness cases in the United States and Europe [4] . One of the major complications is glaucoma which arises secondary to uveitis or the corticosteroids used to treat uveitis [1,[5][6] . Uveitic glaucoma is difficult to manage because it may be difficult to obtain a desirable IOP through medical treatments and surgeries. ...
Aim:
To report long-term outcomes of secondary glaucoma due to uveitis treated with Ahmed glaucoma valve (AGV) implantation in a series of Chinese patients.
Methods:
The retrospective study included 67 eyes from 56 patients with uveitic glaucoma who underwent AGV implantation. Success of the treatment was defined as patients achieving intraocular pressure (IOP) levels between 6 and 21 mm Hg with or without additional anti-glaucoma medications and/or a minimum of 20% reduction from baseline IOP. The main outcome measurements included IOP, the number of glaucoma medications at 1, 3, 6, 12, 24, 36, 48 and 60mo after surgery, surgical complications, final best-corrected vision acuity (BCVA), visual field (VF) and retinal nerve fiber layer (RNFL).
Results:
The mean follow-up was 53.3±8.5 (range 48 to 60)mo. The cumulative probability of success rate was 98.5%, 95.5%, 89.6%, 83.6%, 76.1%, 70.1%, 65.7% and 61.2% at 1, 3, 6, 12, 24, 36, 48 and 60mo, respectively. IOP was reduced from a baseline of 30.8±6.8 to 9.9±4.1, 10.1±4.2, 10.9±3.7, 12.9±4.6, 13.8±3.9, 13.2±4.6, 12.3±3.5 and 13.1±3.7 mm Hg at 1, 3, 6, 12, 24, 36, 48 and 60mo, respectively (P<0.01). The number of postoperative glaucoma medications was significantly decreased compared with baseline at all time points during the study period (P<0.05). There was no significant difference between preoperative and postoperative BCVA. Remarkable surgical complications were not found after surgery. The VF and RNFL of the patients were stable after the surgery.
Conclusion:
AGV implantation is safe and effect in terms of reducing IOP, decreasing the number of glaucoma medications, and preserving vision for patients with uveitic glaucoma.
... In patients with a poor condition, interventional radiologic techniques, such as transjugular intrahepatic portosystemic shunts (TIPS), percutaneous transhepatic obliteration (PTO) and balloon-occluded retrograde transvenous obliteration (B-RTO) have been used successfully for stomal variceal bleeding as a non-surgical option. PTO for stomal variceal bleeding also has been performed successfully [7][8][9][10][11]. The potential complications of PTO include bile leakage, bleeding, liver trauma, and portal vein thrombosis. ...
Background Portal hypertension (PH) is associated with the development of esophageal or gastric varices, which can cause bleedings with high mortality. Varices can also manifest at sites of stomata. These parastomal varices can cause recurrent variceal bleedings (VB) despite local therapies. We present a case series of parastomal VB due to PH that were managed with implantation of transjugular intrahepatic portosystemic shunt (TIPS).
Methods We retrospectively included all patients (pt) from 2 tertiary medical centers with parastomal VB between January 2014 and February 2020 who underwent the TIPS procedure.
Results Nine pt were included. Seven pt had liver cirrhosis, mostly alcohol-related. Two pt had non-cirrhotic PH due to porto-sinusoidal vascular disease (PSD). Four pt had a colostomy, 1 an ileostomy, and 4 an ileal conduit. Malignancy was the leading cause of stoma surgery. All 9 pt suffered from recurrent parastomal VB despite non-selective beta-blocker and/or local therapy (e.g., compression, coagulation, suture ligation, or surgical stoma revision). All pt received TIPS implantation. In 7 pt, TIPS implantation led to sustainable hemostasis. Two pt suffered a bleeding relapse that was attributable to TIPS dysfunction. TIPS revision with coil embolization of the varices terminated the VB sustainably in both pt.
Conclusions In pt presenting with recurrent stomal bleedings, parastomal varices as a rare complication of PH must be taken into consideration as an underlying cause. In our case series, we managed to sustainably cease parastomal VB by TIPS implantation with or without coil embolization of the ectopic varices.
A 57-year-old male presented with intermittent gastrointestinal bleeding (GIB) 1 year after a successful simultaneous pancreas and kidney transplant. No source could be found after 5 tagged red blood cell studies, 3 computed tomographies (CTs), 7 endoscopies, and 4 catheter angiograms. Review of CTs showed pathologically enlarged superior mesenteric vein branches near a jejunal segment near pancreas graft. Transhepatic superior mesenteric venogram showed varicosities near jejunum, which were obliterated with ethylene vinyl alcohol (Onyx). Follow-up CTs confirmed complete obliteration, but he had more GIBs and eventually underwent native jejunal and donor duodenal resection. He has remained GIB-free for 12 months.
Varices may form in any part of the gastrointestinal tract from the esophagus to the colon, when portal pressure increases. The most common site of ectopic varices is the rectum followed by the duodenum. Other sites of varices are the small intestine, colon, gall bladder, anastomotic site, and stoma. The incidence of rectal varices has been increasing in recent years. Patients have to be monitored for possible rectal varices especially after the treatment of esophageal and gastric varices. While cirrhosis is the most frequent underlying disorder in Japan, extrahepatic portal obstruction associated with thrombosis, tumor, or pancreatitis is common in the USA and Europe. Endoscopy to directly observe the variceal lesion is most frequently used for diagnosis. Computed tomography and magnetic resonance imaging are required for understanding the hemodynamic profiles of ectopic varices regardless of their sites. Ectopic varices may be fatal once bleeding occurs because of the high blood flow rate and volume. However, bleeding is considered infrequent in general. Ectopic varices are an important clinical issue in portal hypertension, and the incidence is expected to increase. The pathophysiology of ectopic varices needs to be elucidated to establish the diagnosis and treatment.
