S4832 Parastomal Varices: When Bleeding Demands a Shunt

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 model for end-stage liver disease (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 man 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 1 year, he was hospitalized 7 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.