Varices everywhere: Stomal bleeding due to undiagnosed portal hypertension

Patients with stomas commonly experience bleeding at the stoma site, often due to local mucosal trauma. However, more serious underlying causes should be considered. We discuss the case of a 77-year-old man with a past medical history of colostomy who presented to the emergency department (ED) after an episode of acute stomal bleeding. He had experienced increasingly worsening episodes of superficial stomal bleeding for three years prior to presentation. Computed tomography (CT) revealed an unexpected finding of an ectopic parastomal varix within the stoma, associated with newly discovered cirrhosis and infiltrated hepatocellular carcinoma. Why should an emergency physician be aware of this? Stomal bleeding is usually due to a range of superficial causes. However, parastomal variceal bleeding can be severe and life-threatening. Emergency physicians should consider this diagnosis when encountering a patient with stomal bleeding, especially if the patient has risk factors for portal hypertension.