.jpg "Huda Asif, MD photo")
Huda Asif, MD
University of Miami Leonard M Miller School of Medicine
Atlantis, Florida
Disclosure information not submitted.
Elizabeth Valdes, DO
Resident physician, Internal Medicine
University of Miami Leonard M Miller School of Medicine
Atlantis, Florida, United States
Disclosure information not submitted.
Amit Sah, MD
Resident physician
University of Miami
Atlantis, Florida, United States
Disclosure information not submitted.
Sean Martinez, MD
Radiology
University of Miami
West Palm Beach, Florida, United States
Disclosure information not submitted.
Alexander Restrepo, MD
Gastroentrology
Veteran Affairs Medical Center West Palm Beach
West Palm Beach, Florida, United States
Disclosure information not submitted.
Adam Friedlander, MD, MS
Physician
Orlando Health, United States
Disclosure information not submitted.
Title: Urostomal Variceal Bleed in Ileal Conduit Presenting as Hemorrhagic Shock.
Introduction:
Portosystemic shunts can rarely develop in ileal conduits and represent a very rare site for ectopic varices. We present a case of urostomal varices with recurrent urostomal hematuria in a patient with nonalcoholic cirrhosis.
Description:
70- year-old male with past medical history of prostate cancer status post cystoprostectomy with ileal conduit urinary diversion, recurrent hematuria, and non-alcoholic liver cirrhosis associated with esophageal varices, presented with syncope associated with massive spontaneous urostomal gross hematuria. On presentation, patient was noted to have orthostatic hypotension with a urostomal bag filled with blood and clots. Initial workup was significant for microcytic anemia. CT angiogram of the abdomen was significant for enlarged branches of superior mesenteric vein extending into distal aspect of ileal conduit and anterior abdominal wall varices. Soon after presentation patient developed hemorrhagic shock requiring transfer to the intensive care unit and aggressive resuscitation with fluids and multiple blood transfusions. Patient was emergently taken to the operating room where a bleeding vessel at the distal ileal conduit stomal site was sutured. Once patient was hemodynamically stable, he underwent urgent transjugular intrahepatic portosystemic shunt (TIPS). Transhepatic gradient reduced from 18mmHg to 8mmHg after a successful TIPS without complications. Patients did not experience any further gastrointestinal or urostomal variceal bleed after the procedure. On one month and three months follow up, patient reported the absence of any further urostomal or gastrointestinal bleeding.
Discussion:
Ectopic varices represent 5% of variceal bleeds. Recurrent urostomal hematuria from ileal conduit in patients with liver cirrhosis should prompt a workup for possible variceal bleed. Early diagnosis of urostomal variceal bleed is crucial for timely appropriate management and prevention of complications including hypovolemic shock in patients with liver cirrhosis. Definitive treatment is with TIPS which is associated with resolution of variceal bleed as seen in our patient. Without appropriate diagnosis and treatment, urostomal variceal bleed carries high mortality of 40%.