Recurrent Peristomal Variceal Hemorrhage Secondary to Portal Hypertension: A Diagnostic Pitfall in Metastatic Rectal Cancer

Peristomal varices are an uncommon but important cause of recurrent bleeding in patients with portal hypertension and enterostomies. They may be mistaken for local trauma, mucosal irritation, superficial abdominal wall vessel bleeding, or malignant bowel invasion, delaying definitive management. We present a 72-year-old female patient with stage IV rectal adenocarcinoma metastatic to the liver who developed recurrent stomal hemorrhage initially attributed to small bowel bleeding. Repeat multidisciplinary review of computed tomography angiography demonstrated abnormal peristomal vasculature consistent with portal venous collaterals, favoring peristomal varices as the bleeding source. Recognition of the true bleeding source redirected management toward treatment of portal hypertension with octreotide and non-selective beta blockade and facilitated short-term hemostatic control. This case highlights the importance of considering peristomal varices in patients with recurrent ostomy bleeding and portal hypertension, particularly when standard gastrointestinal bleeding evaluations are unrevealing. Careful reassessment of existing imaging may identify portal venous collaterals and substantially alter management.