Bleeding Stomal Varices and Vascular Interventional Radiology Management: A Case Report

ABSTRACT

Stomal varices are a rare but life‐threatening complication of portal hypertension. While multiple approaches are used to treat these varices, clinicians often face significant diagnostic and therapeutic challenges. A 55‐year‐old woman with a history of cirrhosis and low rectal cancer presented with massive stomal variceal bleeding requiring transfusion support. Emergency bleeding control was achieved using percutaneous NBCA–lipiodol embolization of the dominant feeding vein. Approximately ten months after the initial procedure, the patient experienced another episode of stomal bleeding caused by small collateral varicose veins, requiring blood transfusion, which was effectively treated with ultrasound‐guided targeted local sclerotherapy. No further stomal bleeding recurrence was noted during one year of follow‐up after sclerotherapy. This case highlights the feasibility of two different minimally invasive and accessible techniques, glue embolization and sclerotherapy, in managing bleeding stomal varices in the same patient. The favorable long‐term results support the potential role of these approaches as reliable alternatives for high‐risk surgical patients awaiting liver transplantation or when TIPS is not available.

Key Clinical Message

Bleeding stomal varices after abdominoperineal resection in the setting of portal hypertension can be managed with image‐guided percutaneous therapy when urgent hemostasis is required and TIPS is unavailable. NBCA‐lipiodol embolization and ultrasound‐guided sclerotherapy can control bleeding stomal varices, offering minimally invasive options for high‐risk surgical patients awaiting liver transplantation.

Abbreviations

5FU

5‐fluorouracil

APR

Abdominoperineal resection

BMI

Body mass index

B‐RTO

Balloon‐occluded retrograde transvenous obliteration

CT

computed tomography

ES

Endoscopic sclerotherapy

EVBL

Endoscopic variceal band ligation

GIB

Gastrointestinal bleeding

IMV

Inferior mesenteric vein

JR catheter

Judkins Right catheter

MASLD

Metabolic dysfunction–associated steatotic liver disease

MRI

Magnetic resonance imaging

NBCA

N‐butyl cyanoacrylate

SVB

Stomal variceal bleeding

SVs

Stomal varices

TIPS

Transjugular Intrahepatic Portosystemic Shunt

1. Introduction

Ectopic varices are large portosystemic venous collaterals occurring anywhere in the abdomen except in the cardioesophageal region. Stomal and parastomal varices are ectopic varices observed in patients with portal hypertension and prior ostomies. Ectopic varices are an unusual cause of gastrointestinal hemorrhage, accounting for only 5% of gastrointestinal variceal bleeding. In patients with portal hypertension, bleeding is caused primarily by the rupture of varicose veins [1, 2]. In cases of stomal varices (SVs), bleeding is the most frequent and serious symptom and can be life‐threatening, but in the focal bleeders, it can be controlled by manual pressure. Additionally, bluish skin discoloration (raspberry appearance of stoma) and visible dilated submucosal veins and caput medusae of the stoma in up to one‐third of patients presenting with SV bleeding may be present [3, 4].

It remains uncertain whether SVs are more likely to develop in patients who have undergone bowel resection following portal hypertension or in those with preexisting long‐term ostomies that subsequently develop portal hypertension. The prevalence of SVs is mainly reported based on active bleeding events because diagnosis based on visual or endoscopic evaluation alone remains limited. Bleeding rates range from 27% to 50%, with the onset of bleeding occurring between 1 month and 23 years after stoma formation [4].

After endoscopy and ruling out upper gastrointestinal bleeding, an imaging assessment of the peristomal area should be performed. This includes cross‐sectional imaging using computed tomography (CT) or magnetic resonance imaging (MRI) with a portal venous phase of contrast, direct portal venography, or simply Doppler ultrasound of the peristomal area. There are limited data to choose one imaging modality over others, but cross‐sectional imaging or direct portal venography is likely the best option due to providing other information, such as shunting pathways and presence of portal‐mesenteric thrombosis, and giving providers more information regarding vascular access to the varix [4].

Management strategies vary widely, ranging from local control (manual pressure or pressure dressings, suture ligation, sclerotherapy, intravascular coil, or glue embolization) to portal vein decompression with transjugular intrahepatic portosystemic shunt (TIPS) and liver transplant [5]. In this study, a case of unusual, massive stomal variceal bleeding (SVB) managed via percutaneous glue embolization, with recurrence later treated by sclerotherapy, is reported.

2. Case Presentation

A 55‐year‐old woman with a history of cirrhosis and previously treated low rectal cancer presented to Alzahra Hospital, a tertiary referral center in Isfahan, Iran, with a severe episode of SVB.

2.1. Oncologic History

The patient was diagnosed with low rectal cancer (well‐differentiated adenocarcinoma, Grade 2) in September 2017. Initial staging with endoscopic ultrasound demonstrated T3N1Mx disease. She subsequently underwent neoadjuvant chemoradiotherapy between November 2017 and January 2018, consisting of folinic acid, 5‐fluorouracil (5FU), and oxaliplatin, along with supportive medications including dexamethasone, granisetron, granulocyte colony‐stimulating factor (filgrastim), and heparin. Between chemotherapy cycles, she received danazol, folic acid, and tranexamic acid. Radiotherapy was subsequently delivered in 28 sessions. Posttreatment MRI demonstrated significant tumor regression, corresponding to T1/2N0M0 disease with minimal residual tumor.

In February 2018, the patient underwent abdominoperineal resection (APR) with permanent left lower quadrant colostomy. Histopathological examination revealed complete regression of the primary tumor (ypT0) with residual nodal disease (N1b), as two out of seven resected lymph nodes remained positive for malignancy. No lymphovascular or perineural invasion was identified, and all surgical margins were free of tumor. Only treatment‐related changes, including fibrosis, necrosis, and ulceration, were observed. Additional lymph node dissections from the iliac and obturator regions were negative, and the final staging was ypT0N1bM0. Following completion of adjuvant chemotherapy in March and May 2018, the patient achieved a complete clinical remission and remained without evidence of disease (NED) on subsequent clinical and imaging follow‐up evaluations (CT scan, MRI, and colonoscopy) to date.

2.2. Hepatic Disease and Varices

Approximately three years after surgery, in September 2021, the patient developed gastrointestinal bleeding (GIB) and was diagnosed with esophageal varices (F1–2), raising suspicion for portal hypertension. Further evaluation confirmed metabolic dysfunction–associated steatotic liver disease (MASLD) with significant steatosis. FibroScan demonstrated a liver stiffness measurement of 8.7 kPa, corresponding to F2 fibrosis, and a controlled attenuation parameter of 300 dB/m, consistent with S3 steatosis. A subsequent liver core needle biopsy performed in January 2022 revealed chronic hepatitis (Grade 1/4) with fibrosis staged as 3/6 according to the Ishak system and Stage 2/4 according to the Batts and Ludwig classification. Several prior therapeutic agents were considered potential contributors to this hepatic injury and MASLD progression. However, a definitive causal relationship could not be established, and these associations remain speculative. The following agents are discussed as potential contributors: Oxaliplatin may induce sinusoidal obstruction syndrome and contribute to portal hypertension, while 5FU has been associated with hepatic steatosis. Corticosteroids such as dexamethasone may exacerbate metabolic dysfunction in patients with MASLD, and danazol is known for its hepatotoxic potential, including cholestatic injury and fatty liver changes. It is also possible that other unrecognized or multifactorial etiologies contributed to the development and progression of liver disease.

The patient underwent intermittent endoscopic variceal band ligation (EVBL) for management of esophageal varices. The first episode of stomal bleeding occurred in December 2022 and was managed conservatively with tranexamic acid following surgical consultation. During this episode, the patient was admitted for colostomy site bleeding, received two units of packed red blood cells, and was subsequently discharged without the need for surgical intervention and continued to receive tranexamic acid for a while. Endoscopic evaluations were suggested but not completed.

2.3. Clinical Status at Presentation and Imaging

A second episode of stomal bleeding occurred one year later, in December 2023. During this episode, the patient had active bright red bleeding from the colostomy site without fecal admixture, suggesting an ectopic source of hemorrhage. Endoscopic evaluation demonstrated intact esophageal varices (F1), further supporting a non‐esophageal origin of bleeding. At presentation, laboratory evaluation revealed a hemoglobin level of 9 g/dL, platelet count of 60,000/μL, international normalized ratio (INR) of 1.54, creatinine level of 1 mg/dL, total bilirubin of 0.8 mg/dL, sodium level of 143 mEq/L, and albumin level of 4.4 g/dL. Mild ascites was present. The MELD‐Na score was calculated at 11, and the Child–Pugh score was 6, corresponding to class A cirrhosis. The patient received 10 cryoprecipitate transfusions.

Abdominopelvic CT scan in the portal venous phase demonstrated a dilated inferior mesenteric vein (IMV) with prominent collateral vessels extending through the rectus abdominis muscle and draining into the peristomal skin, findings consistent with stomal varices. No evidence of thrombosis was identified in the portal vein, superior mesenteric vein (SMV), or IMV (Figure 1).

FIGURE 1.

Axial abdominopelvic CT with IV contrast obtained in the portal venous phase showed dilated IMV (red arrow) and tortuosity, which passes the rectus abdominis muscle (blue arrows) and drains to the skin. The yellow arrow indicates a varicose vein.

2.4. Additional Medical and Drug History

She had previously undergone total thyroidectomy for nodular goiter and was maintained on levothyroxine. Twelve months after APR, in March 2019, a surveillance colonoscopy revealed a single transverse colon polyp, which was resected and confirmed to be a benign hyperplastic polyp on histopathological examination. One of the upper gastrointestinal endoscopies in October 2022 revealed gastritis and Helicobacter pylori infection, along with F3 esophageal varices, which were treated with EVBL and antibiotics. She was receiving propranolol 20 mg twice daily and daily supplements. Her body mass index was 30.5, consistent with obesity. She was a lifetime nonsmoker and reported no alcohol consumption. Family history was notable for renal, skin, and brain malignancies.

2.5. Management and Outcome

2.5.1. First Procedure and Outcome

Considering the patient's underlying cirrhosis, history of multiple abdominal surgeries, and elevated surgical risk, operative intervention was considered unfavorable. In addition, TIPS was not available. Therefore, a percutaneous interventional radiology approach with embolization was selected as the most appropriate therapeutic strategy, balancing feasibility, safety, and accessibility. On the day of the procedure, she received transfusion of 2 units of fresh frozen plasma (FFP) and 3 units of platelets. Follow‐up laboratory values on the next day demonstrated a hemoglobin level of 8.5 g/dL, platelet count of 62,000/μL, and INR of 1.52.

The procedure was performed in the angiography room with the patient in the supine position under sedation with propofol. Under real‐time sonographic guidance, a variceal vessel adjacent to the colostomy site was punctured, and a 5F sheath was introduced through the abdominal wall. A hydrophilic guidewire was advanced, and a Judkins Right catheter was used to access the junction of the IMV and the portal vein. Subsequently, a microcatheter was advanced and positioned approximately 5 cm distal to the IMV–portal vein junction.

Given the direction of blood flow from the portal vein toward the variceal network, the risk of nontarget embolization was considered low, and no additional preventive measures were required. A 1:1 mixture of n‐butyl cyanoacrylate (NBCA) and Lipiodol (2 cc total volume) was then slowly injected under fluoroscopic guidance. During the gradual withdrawal of the microcatheter, additional glue was administered to ensure complete filling of the variceal tract. Formation of a dense glue cast was observed, extending through the collateral vessels and peristomal varices, with complete occlusion of the feeding pathway as the procedural endpoint.

The procedure was completed within 30 min without immediate complications. Hemostasis was achieved, and the patient remained free of recurrent stomal bleeding and hemodynamically stable. She was discharged after observation by the gastroenterology team. Follow‐up CT confirmed successful obliteration of the variceal network without evidence of residual flow or recurrent dilation (Figure 2). No further episodes of stomal bleeding occurred for ten months following the procedure, although one session of endoscopic variceal band ligation was performed five months later for esophageal varices.

FIGURE 2.

Axial abdominopelvic CT with IV and PO contrast obtained in the portal venous phase showed fibrotic IMV (red arrow) and glue in the previous varicose veins (yellow arrow). Dilated or varicose vein around the colostomy and superficial rectus abdominis muscle are not seen.

2.5.2. Recurrence and Second Procedure

Approximately ten months after the initial embolization, the patient presented with recurrent bleeding from the colostomy site. She was admitted in October 2024 and underwent further evaluation, including upper endoscopy, which revealed F1‐grade esophageal varices that did not require band ligation. A few days later, she experienced a severe bleeding episode, necessitating transfusion of three units of packed red blood cells.

Laboratory findings prior to the second intervention demonstrated a hemoglobin level of 7.1 g/dL, platelet count of 68,000/μL, creatinine level of 1 mg/dL, total bilirubin of 0.5 mg/dL, INR of 1.44, sodium level of 140 mEq/L, and albumin level of 3.8 g/dL. Moderate ascites was present. The MELD‐Na score was 11, and the Child–Pugh score was 7 (class B).

CT imaging revealed a fibrotic IMV without evidence of recanalization of the previously embolized tract. However, multiple newly formed collateral varices were identified around the colostomy site. These vessels were diffuse, fine (< 2 mm), and tortuous, arising through accessory venous pathways secondary to portal hypertension (Figure 3).

FIGURE 3.

Axial abdominopelvic CT scan with intravenous (IV) contrast obtained in the portal venous phase during the second episode. The blue arrow indicates fibrotic IMV. Yellow arrows indicate small collateral varicose veins that caused bleeding. Zoomed‐out abdominopelvic CT scan.

Owing to the small caliber and the presence of multiple feeding channels, selective catheterization was technically not feasible. In addition, the previously embolized pathway remained completely occluded and fibrotic, confirming that recurrence was not due to IMV recanalization. Because TIPS remained unavailable and the variceal condition limited the endovascular access, percutaneous sclerotherapy was selected as the most appropriate therapeutic approach.

Under combined sonographic and fluoroscopic guidance, multiple collateral vessels surrounding the colostomy site were accessed percutaneously using a blue‐gauge intravenous cannula at several puncture sites. A sclerosing solution consisting of bleomycin (30 IU across two vials) mixed with normal saline, dextrose water, and Lipiodol (total volume approximately 20 mL) was injected into the targeted vessels.

Three days after the procedure, follow‐up ultrasonography demonstrated thrombosis or disappearance of the majority of the treated vessels. The patient remained clinically stable and was discharged four days after the intervention without complications.

2.5.3. Follow‐Up and Current Status

Ten months after the second intervention, the patient remained free of bleeding from colostomy varices, and she only experienced another episode of esophageal bleeding, which was managed with transfusion of two units of packed red blood cells and EVBL. Follow‐up CT scan at that time showed no evidence of dilated stomal varices (Figure 4).

FIGURE 4.

(A) Axial abdominopelvic CT angiography with IV contrast obtained in the arterial phase, performed 10 months after the second procedure, showed no evidence of dilated varicose vein or dilated IMV. (B) Magnified view of panel A. The red arrow indicates the descending colon. The yellow arrow indicates IMA. The blue arrow indicates previous fibrotic IMV. The green arrows indicate previous fibrotic variceal veins.

The patient is currently under evaluation for liver transplantation. Pretransplant laboratory values demonstrated relatively preserved liver function, with hemoglobin levels ranging from 12 to 13 g/dL, platelet counts between 72,000 and 140,000/μL, creatinine level of 1 mg/dL, total bilirubin of 0.9 mg/dL, albumin level of 4.6 g/dL, sodium level of 143 mEq/L, and INR of 1.33, with minimal or no ascites. The MELD‐Na score remained approximately 10, and the Child–Pugh classification ranged between 5 and 6 (class A). All clinical details are summarized in Figure 5.

FIGURE 5.

Clinical timeline of the patient's medical history, interventions, and follow‐up.

Although the patient is currently a candidate for liver transplantation, the occurrence of further severe bleeding episodes during the waiting period may necessitate expedited referral for TIPS, irrespective of transplant eligibility.

3. Discussion

Although bleeding in stomal varices is rare, it is associated with significant morbidity and mortality, and the rate of rebleeding is also high (mortality might be as high as 40%). Multiple approaches are used to treat a variceal ostomy, ranging from local measures to surgery. Local therapy, such as manual pressure or pressure dressings, suture ligation, sclerotherapy, intravascular coil, or glue embolization, is preferred as first‐line treatment in many cases, and they can efficiently control stomal variceal bleeding immediately. However, none of these methods address the underlying cause of the varices, which is portal hypertension [2, 5].

As an intervention for SVB, TIPS decompresses the stomal varices by lowering elevated portal pressure. TIPS is considered an alternative therapeutic intervention in the setting of variceal bleeding with generalized oozing secondary to congestion caused by portal hypertension. This intervention may effectively reduce portal hypertension and has been shown to alleviate hepatic congestion and bleeding. TIPS is only recommended as a primary technique in high‐risk patients after the first variceal bleed, and this technique is not recommended as primary prophylaxis due to the invasive nature of the TIPS procedure and the relatively higher procedure‐related mortality and complications [2, 6]. In the long‐term, TIPS is associated with a high rebleeding rate of about 21%–37% in patients with ectopic varices [3]. Furthermore, patients with a history of previous abdominal surgery, pulmonary hypertension, poor hepatic reserve, and/or liver disease/portal hypertension in the setting of inflammatory bowel disease are not ideal candidates for TIPS procedures [6].

In some cases, coil embolization may be used alongside TIPS to manage varices, although it comes with the risk of coil erosion into the lumen and stoma. In this situation, there is a risk of coils eroding into the lumen and stoma. In addition to TIPS, variceal embolization significantly lowers the recurrence rate. Embolization using glue (N‐butyl cyanoacrylate) provides a better variceal obliteration than coil embolization. The glue may be more effective in obliterating small and distal venous channels, in contrast to the more proximal embolization by coils. A percutaneous transhepatic approach may be considered when TIPS is not an option, although it carries risks of intra‐abdominal bleeding and liver injury. Local sclerotherapy is also a way to treat SVB with mixed outcomes, but the sclerosant can cause stomal damage. Due to higher morbidity and mortality rates, surgical portosystemic shunts are rarely recommended. The most definitive treatment for stomal varices would be reversal of the ileostomy or colostomy, if it is medically and anatomically feasible. Ostomy reversal is commonly not surgically possible, especially in the setting of liver cirrhosis and portal hypertension [2, 3].

Liver transplantation is the most effective treatment for patients with advanced liver cirrhosis and liver failure. However, many of these patients have comorbidities that may prohibit this option and the construction of surgical shunts. TIPS combined with variceal embolization is an effective treatment for SVB. Due to the various contraindications of TIPS, percutaneous transhepatic plug‐assisted glue embolization offers a viable alternative for some patients [2, 3, 7].

Cyanoacrylate glues are liquid alkyl‐2‐cyanoacrylate monomers. These monomers form flexible polymers with adhesive bonds to soft tissues when they contact ionic mediums such as water or blood. These liquid monomers are nonviscous, radiolucent, and polymerize quickly in isolation. They are used as a two‐component embolic agent with either tantalum powder or ethiodized oil. The added agent extends polymerization time, opacifies the liquid agent, and allows for its visualization under fluoroscopy. Among these, NBCA has been successfully applied in a variety of clinical settings, including vascular embolization and closure of gastrointestinal fistulas. Previous work has demonstrated the effective use of NBCA for the minimally invasive closure of jejunocutaneous fistulas in a patient with Crohn's disease, showing sustained closure and symptom resolution over long‐term follow‐up [8, 9].

Sclerotherapy, one of the least invasive procedures, has been reported as a successful and relatively safe procedure for parastomal and stomal variceal bleeding in previous studies. However, in this procedure, some undesirable damage may occur to the stoma, including retraction, ulceration, and stricturing [5, 10]. Ultrasound‐guided sclerotherapy with liquid and foam sclerosants has proved to be an effective supplement to the numerous treatments available for varicose veins [11]. Uhlenhopp et al. presented a case of a 51‐year‐old patient who developed bleeding ileostomy varices that were effectively treated under direct ultrasound‐guided percutaneous sclerotherapy. They considered this method a safe and effective management for acute bleeding stomal varices in decompensated cirrhotic patients [5]. Endoscopic sclerotherapy (ES) is a therapeutic method that is usually used for gastroesophageal varices and isolated gastric varices. ES also has great clinical value in achieving hemostasis for isolated (ectopic) varices and stomal varices. In ES, a sclerosant is injected into the varices and causes tissue irritation, leading to vessel thrombosis and hemostasis [10, 12].

Transcatheter sclerotherapy is categorized into retrograde transcatheter sclerotherapy and antegrade transcatheter sclerotherapy. Among retrograde transcatheter sclerotherapy techniques, balloon‐occluded retrograde transvenous obliteration (B‐RTO) is recognized as a safe and effective treatment for gastric varices with a gastrorenal shunt in Japan. An intra‐institutional study comparing TIPS and transcatheter sclerotherapy alone for treatment of bleeding gastric varices revealed that transcatheter sclerotherapy may provide better control of gastric variceal bleeding than TIPS. Moreover, transcatheter sclerotherapy may be more useful than TIPS due to its influence on liver function [6, 13]. In this case, percutaneous venography and percutaneous transcatheter injection of n‐butyl cyanoacrylate (NBCA) glue for management was performed due to the absence of suitable equipment and specialists for TIPS. Glue embolization was preferred over sclerotherapy because of the large size of the varicose vessel and its blood supply from the superior mesenteric vein (SMV), as this technique is associated with greater efficacy and a lower recurrence rate in such cases. In the second episode, the situation was managed with sclerotherapy due to the small and numerous vascular networks around the colostomy site.

4. Conclusion

There are multiple approaches used to treat ectopic varices secondary to portal hypertension that range from local measures to surgery. Embolization using glue (N‐butyl cyanoacrylate) is effective in obliterating the small and distal venous channels. Local sclerotherapy is also a way to treat SVB with mixed outcomes. These two minimally invasive techniques can be effective for the urgent management of stomal variceal bleeding in high‐risk surgical patients when TIPS is unavailable or when there is a prolonged waiting time for liver transplantation.

Author Contributions

Paria Bolourinejad: project administration, writing – review and editing. Pardis Tavallaeinejad: data curation, writing – original draft. Mohammad Saleh Jafarpisheh: data curation, methodology, supervision.

Funding

The authors have nothing to report.

Ethics Statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the institutional scientific board (scientific ID: 1404162) in Isfahan University of Medical Sciences. Ethical approval was obtained from the Research Ethics Committee of the Alzahra Research Centers, Isfahan University of Medical Sciences, Isfahan, Iran (approval ID: IR.ARI.MUI.REC.1404.195). Informed consent was obtained from the participant included in the study. Consent for publication was obtained for the person’s data included in the study.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.