Abstract
INTRODUCTION
Portal hypertension is an unusual complication of liver metastases, which is frequently occurring in malignant disease. Portal hypertension may cause oesophageal varices and also stoma varices (colostomy and ileostomy). Oesophageal varices and bleeding from these varices have been frequently reported in literature. Stomal varices have also been reported in literature mostly associated with liver cirrhosis. These stomal varices lead to the massive bleeding causing morbidity and mortality.
Portal hypertension is a pathological increase in portal pressure gradient (the difference between pressure in the portal and inferior vena cava veins). It is either due to an increase in portal blood flow or an increase in vascular resistance or combination of both. In liver cirrhosis, the primary factor leading to portal hypertension is increase in portal blood flow resistance and later on development of increased portal blood flow. It has been postulated that in liver metastasis the increase in portal flow resistance occurs at any site within portal venous system as a consequence of mechanical architectural disturbance.
PRESENTATION OF CASE
We report a case of a 64 year old gentleman who developed portal hypertension due to secondary metastases from colorectal cancer. He subsequently developed bleeding varices in his end colostomy.
DISCUSSION
We believe that the combination of extensive metastases and chemotherapy induced portal hypertension in our patient.
CONCLUSION
Our case and other literature review highlight that the recurrent bleeding stoma associated with colorectal cancer should be investigated for portal hypertension.
Keywords: Stoma varices, Portal hypertension, Liver metastases
1. Introduction
Portal hypertension is an unusual complication of liver metastases, which is frequently occurring in malignant disease. Portal hypertension may cause oesophageal varices and also stoma varices (colostomy and ileostomy). Oesophageal varices and bleeding from these varices have been frequently reported in literature. Stomal varices have also been reported in literature mostly associated with liver cirrhosis. These stomal varices lead to the massive bleeding causing morbidity and mortality.1 There are significant risks and cost associated with variceal bleeding including repeated hospitalization, blood transfusions, expenses and inconvenience.
Portal hypertension is a pathological increase in portal pressure gradient (the difference between pressure in the portal and inferior vena cava veins). It is either due to an increase in portal blood flow or an increase in vascular resistance or combination of both. In liver cirrhosis, the primary factor leading to portal hypertension is increase in portal blood flow resistance and later on development of increased portal blood flow. It has been postulated that in liver metastasis the increase in portal flow resistance occurs at any site within portal venous system as a consequence of mechanical architectural disturbance.
We report a case of a 64 year old gentleman who developed portal hypertension due to secondary metastases from colorectal cancer. He subsequently developed bleeding varices in his end colostomy.
2. Case history
A 64 year old patient presented with a change in bowel habit of two years duration and marked weight loss. On examination he had a palpable liver and colonoscopy revealed a large polyploidal tumour in the rectum. Subsequent histology confirmed an adenocarcinoma. The staging CT scan showed extensive liver metastasis and staged as T3N1M2 (Fig. 1). He then underwent palliative Hartmann's procedure plus adjuvant chemoradiotherapy. He received nine cycles of oxaliplatin and 5-FU over a period of 5 months, which were discontinued due to the development of myelosuppression. A further chemotherapy course of oxaliplatin and 5-FU was commenced the following year (3 cycles) but was also discontinued due to thrombocytopenia. Bone marrow biopsy revealed dysplastic changes secondary to chemotherapy. A follow-up CT scan eighteen months later reported a twenty fold increase in liver metastases and he was offered palliative chemotherapy with oxaliplatin, 5-FU, irinotecan and GCSF support (6 cycles over a 2 month period). His first episode of bleeding from the stomal edges was in July 2009, which was managed by applying pressure and silver nitrate.
Fig. 1.
CT scan showing extensive liver metastases and dilated IMV.
He further had five different admissions in the following three months with bleeding requiring blood transfusions. Local measures were used to manage the bleeding such as suture ligation and sclerotherapy. A CT scan was performed and it revealed dilated mesenteric vessels (Fig. 1) suggesting portal hypertension (35 mmHg) with multiple varices noted at the colostomy site (Fig. 2). Percutaneous transhepatic embolisation of the inferior mesenteric vein (IMV) was performed in Oct 2009. (Figs. 3–5) The patient was followed up for six months and had no more bleeding from his colostomy (Figs. 6 and 7).
Fig. 2.
CT scan showing stoma varices.
Fig. 3.
Pre-embolisation angiogram.
Fig. 4.
Post-embolisation angiogram.
Fig. 5.
Post-procedure angiogram.
Fig. 6.
CT scan showing IMV after treatment.
Fig. 7.
CT scan showing extensive liver metastases after treatment.
3. Discussion and literature review
Blood flow through the portal system is approximately 1500 ml per minute. One third flows via the hepatic artery and two thirds via the portal vein. The normal portal pressure is 5 mmHg. Liver cirrhosis is the most common cause of portal hypertension in the western world and may result in varices. The varices are most commonly seen in oesophagus and gastric fundus. Ectopic varices are found in other parts of GI tract and very rarely may result in stoma.2
Stomal variceal bleeding has been reported in 25% of patients with chronic liver disease. However, it is difficult to differentiate between the variceal bleeding secondary to chronic liver disease or from lower GI tract causes.3
Stomal varices have been reported in patients treated for inflammatory bowel disease in particular secondary to primary sclerosing cholangitis.4 Portal hypertension causing stomal varices due to extensive liver metastasis has never been reported.
Our patient had extensive liver metastases and a primary rectal carcinoma (T3N1M2). He received palliative chemotherapy (oxaliplatin and 5FU) and radiotherapy but liver metastases progressed to twenty fold within an 18 month period.
Tisman et al. reported portal hypertension in patients receiving oxaliplatin in their case series.5 Rubbia-Brandt et al. reported perisinusoidal fibrosis, severe sinusoidal obstruction, and fibrotic venular occlusion as changes noted in liver biopsy specimens in 44 (51%) of 87 of hepatectomies performed after neoadjuvant chemotherapy, and in 34 (79%) of 43 colorectal cancer patients receiving oxaliplatin.6 Hubert et al. described nodular regenerative hyperplasia causing portal congestion and sinusoidal dilatation and hence obliterative portal venopathy due to oxaliplatin and 5FU.7 Similarly radiotherapy may induce liver injury, causing fibrosis and subsequent increase in portal pressure. This is known as radiotherapy induced liver disease (RILD), and it can develop from 4 to 8 weeks after finishing the treatment.8
We believe that the combination of extensive metastases and chemotherapy induced portal hypertension in our patient. Although the mortality is low from bleeding per stoma, it is associated with high morbidity and cost. The recurrent stomal bleeding may require subsequent blood transfusions and hospital admissions.9
Prompt investigations help in accurate diagnosis and management of these cases. This patient underwent successful percutaneous transhepatic embolisation of the inferior mesenteric vein (IMV) and had no bleeding after six months follow up.
To our knowledge no article has been published describing the association of extensive liver metastases and portal hypertension. The management may be challenging and the underlying cause of the bleeding should be treated.
4. Conclusion
Our case and other literature review highlight that the recurrent bleeding stoma associated with colorectal cancer should be investigated for portal hypertension.
Conflict of interest statement
None.
Funding
None.
Ethical approval
Written consent obtained.
Author contributions
E. Theophilidou—writing of case report.
N. Waraich—writing of case report.
T. Raza—writing of case report.
P.K. Agarwal PK—overview of case report.
References
- 1.Ryu R.K., Nemceck A.A., Chrisman H.B., Saker M.B., Blei, Omary R., Vogelzang R.L. Treatment of stomal variceal haemorrhage with TIPS: case report and review of the literature. Cardiovasc Intervent Radiol. 2000;23(July–August (4)):301–303. doi: 10.1007/s002700010073. [DOI] [PubMed] [Google Scholar]
- 2.Alkari B., Shaath N.M., El-Dhuwaib Y., Aboutwerat A., Warnes T.W., Chalmers N. Transjugular intrahepatic porto-systemic shunt and variceal embolisation in the management of bleeding stomal varices. Int J Colorectal Dis. 2005;20(September (5)):457–462. doi: 10.1007/s00384-004-0669-2. [Epub 2005 January 14] [DOI] [PubMed] [Google Scholar]
- 3.Fucini C., Wolff B.G., Dozois R.R. Bleeding from peristomal varices: perspective on prevention and treatment. Dis Colon Rectum. 1991;34:1073–1078. doi: 10.1007/BF02050064. [DOI] [PubMed] [Google Scholar]
- 4.Weisner R.H., LaRusso N.F., Dozois R.R. Peristomal varices after proctocolectomy in patients with primary sclerosing cholangitis. Gastroenterology. 1986;90:316–322. doi: 10.1016/0016-5085(86)90926-1. [DOI] [PubMed] [Google Scholar]
- 5.Tisman G., MacDonald D., Shindell N., Reece E., Patel P., Honda N. Oxaliplatin toxicity masquerading as recurrent colon cancer. J Clin Oncol. 2004;22(15):3202–3204. doi: 10.1200/JCO.2004.99.106. [DOI] [PubMed] [Google Scholar]
- 6.Rubbia-Brandt L., Audard V., Sartoretti P., Roth A.D., Brezault C., Le Charpentier M. Severe hepatic sinusoidal obstruction associated with oxaliplatin-based chemotherapy in patients with metastatic colorectal cancer. Ann Oncol. 2004;15(March (3)):460–466. doi: 10.1093/annonc/mdh095. [DOI] [PubMed] [Google Scholar]
- 7.Hubert C., Sempoux C., Horsmans Y., Rahier J., Humblet Y., Machiels J.-P. Nodular regenerative hyperplasia: a deleterious consequence of chemotherapy for colorectal livermetastases? Liver Int. 2007;27(September (7)):938–943. doi: 10.1111/j.1478-3231.2007.01511.x. [DOI] [PubMed] [Google Scholar]
- 8.Jakobs T.F., Saleem S., Atassi B., Reda E., Lewandowski R.J., Yaghmai V. Fibrosis, portal hypertension, and hepatic volume changes induced by intra-arterial radiotherapy with 90yttrium microspheres. Dig Dis Sci. 2008;53(September (9)):2556–2563. doi: 10.1007/s10620-007-0148-z. [Epub 2008 January 31] [DOI] [PubMed] [Google Scholar]
- 9.Ackerman N.B., Graeber G.M., Fey J. Enterostomal varices secondary to portal hypertension: progression of disease in conservatively managed cases. Arch Surg. 1980;115:1454–1455. doi: 10.1001/archsurg.1980.01380120028007. [DOI] [PubMed] [Google Scholar]