S5701 Recurrent Peristomal Bleeding at a Urostomy Site Due to Portal Hypertension

Introduction: Portal hypertensive enteropathy (PHE) are pathological and mucosal abnormalities seen in the small intestine as a result of portal hypertension. They’re classified into 2 categories: mucosal inflammatory abnormalities such as erythema or friability and vascular lesions like telangiectasias, or varices. These changes are most commonly seen within gastrointestinal tract; however, rarely can be seen at stomal sites, including colostomies, ileostomies, and rarely urostomies. Here we present a case of urostomy site bleeding in a patient with newly diagnosed portal hypertension. Case Description/Methods: A 58-year-old man with a past medical history of bladder cancer, with a permanent urostomy, presented for evaluation after recent hospitalization due to large volume recurrent bleeding from his urostomy site requiring intravenous iron and transfusions. A computed tomography (CT) scan done revealed prominent vasculature at the urostomy. Interventional radiology performed an ultrasound and fluoroscopy-guided venography, confirming the presence of peristomal varices. Embolosclerotherapy was performed, and the portosystemic pressure gradient was 12 mmHg, consistent with portal hypertension. Subsequent evaluation for portal hypertension was done. Fibroscan revealed advanced fibrosis (F4), confirming the diagnosis cirrhosis, secondary to metabolic dysfunction-associated steatohepatitis (MASH) and chronic alcohol use. Despite initial treatment, the patient continued to have intermittent bleeding. He was started on carvedilol 6.25 mg twice daily which was then uptitrated to 12.5 mg due to continued oozing from the urostomy. He stopped drinking and lost 25 lbs but bleeding persisted. Endoscopy showed non-bleeding small varices in the urostomy, 3 cm in from the skin and changes of PHE. Silver nitrate cauterization was done. Plans were made for potential TIPS if bleeding persists. Discussion: Here we report the first case of urostomy bleeding due to portal hypertension. Parastomal bleeding is a serious potential complication in patients with stomas who also have portal hypertension. Commonly seen at colostomies and ileostomies, urostomy site bleeding represent an even rarer anatomical location for this pathology, with no documented cases described in the literature. Management requires a multidisciplinary approach including non-selective beta-blockers, endoscopic therapy like band ligation, interventional radiology techniques such as sclerotherapy and embolization, and in refractory cases, surgical revision or TIPS.