Exsanguinating hemorrhage from urinary ileal conduit in patient with portal hypertension

Muscle-Invasive Bladder Cancer in Patients with Liver Cirrhosis: A Review of Pertinent Considerations

The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.

Bleeding stomal varices: case series and systematic review of the literature

BACKGROUND & AIMS

Bleeding stomal varices are a common problem in patients with surgical stomas and portal hypertension, and remain difficult to diagnose and manage.

METHODS

We identified all patients at our institution with bleeding stomal varices from 1989 to 2004. We surveyed all patients undergoing ileal pouch-anal anastomosis from 1997 to 2007 for bleeding anastomotic varices. Finally, we performed a systematic review of the literature focusing on diagnosis and treatment of bleeding stomal varices that included 74 English language studies of 234 patients.

RESULTS

We identified 8 patients with bleeding stomal varices. Recognition of stomal varices typically was delayed, particularly when failing to examine the ostomy without the appliance. Stomal variceal bleeding was confirmed by Doppler ultrasound or angiographic imaging. Simple local therapy usually stopped bleeding, albeit temporarily. Sclerotherapy was effective, but at the expense of unacceptable stomal damage. Decompressive therapy was required for secondary prophylaxis, including transjugular intravascular transhepatic shunts (2 patients), surgical portosystemic shunts (2 patients), and liver transplantation (1 patient). No patient with an ileal pouch-anal anastomosis developed anastomotic bleeding from varices.

CONCLUSIONS

Primary prevention of bleeding stomal varices requires avoidance of creating enterocutaneous stomas in patients with portal hypertension. Careful inspection of the uncovered ostomy is essential for bleeding stomal varices diagnosis. Once identified, conservative measures will stop bleeding temporarily with definitive therapy required, including transjugular intravascular transhepatic shunts, surgical shunts, or liver transplantation.

Recurrent hemorrhage for ileal conduit: an uncommon complication of portal hypertension

Massive hemorrhage from an ileal conduit is rare. We report who presented with massive recurrent hemorrhage from previously undiagnosed ileal conduit varices secondary to portal hypertension. Current methods for diagnosis and treatment of this rare but life threatening entity are discussed.

Recurrent urinary conduit bleeding in a patient with portal hypertension: management with a transjugular intrahepatic portosystemic shunt

OBJECTIVE

To determine if a transjugular intrahepatic portosystemic shunt can control recurrent urinary conduit bleeding in a patient with portal hypertension.

METHODS

Following transjugular catheterization of the right hepatic vein, a long curve Colapinto needle was advanced through the liver parenchyma into the portal vein near its bifurcation. After a guide wire exchange, a catheter was advanced into the portal system and venogram was obtained. Following another guide wire exchange, a balloon angioplasty catheter was used to create the shunt by dilating the parenchymal tract between the hepatic and portal veins. A self-expandable stent was used to ensure patency of the shunt.

RESULTS

After shunt placement, bleeding from the ileal conduit and stroma decreased significantly. A duplex ultrasound at five-month follow-up demonstrated the shunt to be completely patent.

CONCLUSIONS

Based on this limited experience, it appears that the transjugular, intrahepatic, portosystemic shunt is an acceptable method to control massive, recurrent urinary conduit bleeding in patients with portal hypertension.

Bleeding from peristomal varices: perspectives on prevention and treatment

Peristomal variceal bleeding is a serious complication in patients with chronic liver disease undergoing colon surgery with a stoma. Our aim was to examine the morbidity of bleeding for peristomal, perianastomotic, and esophageal varices in a group of patients with chronic liver disease who underwent colectomy at the Mayo Clinic between 1970 and 1988. Morbidity was evaluated in terms of the number of major bleeding episodes and the number of units of blood transfused. The treatment of bleeding was also evaluated. One hundred seventeen patients (74 males and 43 females) aged 11-78 years were studied. Sixty-two patients (53 percent) had a permanent stoma, while 55 patients (47 percent) had a colonic resection and anastomosis. Sixty-seven patients (62 percent) had chronic ulcerative colitis and primary sclerosing cholangitis. In the stoma group, bleeding appeared from stomal and/or esophageal varices in 19 patients (31 percent), while, in the non-stoma group, bleeding exclusively from the esophageal varices occurred in eight patients (15 percent). Perianastomotic variceal bleeding was never observed. The 5-year cumulative probabilities of one major bleed occurring from gastrointestinal varices appeared to be similar between the two groups. Patients who bled from peristomal varices with or without esophageal bleeding (n = 17) rebled more frequently (6.5 +/- 5.5 vs. 3 +/- 1.6; P less than 0.05) and were transfused more often (14.9 +/- 12.3 vs. 7.5 +/- 4.1; P less than 0.05) than patients who bled exclusively from esophageal varices (n = 10). No difference was found in the incidence of recurrent bleeding and the number of units of blood transfused between patients who bled exclusively from peristomal varices (n = 10) and those who bled from both peristomal and esophageal varices (n = 7). Medical and local measures were more effective in controlling esophageal bleeding than in controlling peristomal bleeding. Therefore, patients with chronic liver disease who must undergo colectomy should have a distal anastomosis rather than a terminal stoma.

Treatment of bleeding stomal varices. Report of a case and review of the literature

Variceal bleeding from ileostomy, colostomy, or ileal conduit stomas is unusual. There is no consensus on which of the various treatment options is best. A case of bleeding ileostomy varices is presented. The English-language medical literature since 1962 is reviewed and an additional 71 cases of stomal variceal bleeding are identified. Treatment options evaluated include stomal manipulation, variceal ligation, sclerotherapy, beta blockade, and surgical shunting. The incidence of rebleeding, requirement for additional procedures, and survival with the various options are compared. Although stomal manipulation was the most commonly performed procedure, portosystemic shunting had the lowest incidence of both rebleeding and need for additional procedures (4 percent each) and provided the longest mean postoperative survival (50 months). The authors conclude that portosystemic shunting is the treatment of choice in patients with bleeding from stomal varices who are good surgical candidates.

Massive bleeding from an ileal conduit caput medusae

A caput medusae developing around an ileal conduit stoma heralded the onset of portal hypertension and recurrent episodes of massive stomal bleeding in a patient with liver cirrhosis. A review of the literature suggests that conservative local measures remain the treatment of choice in the high risk cirrhotic patient.

Parastomal haemorrhage from an ileal conduit secondary to portal hypertension

A case of parastomal haemorrhage around an ileal conduit is presented and the literature reviewed. Simple methods of treatment, such as good stoma care, vitamin K, direct pressure and ligation of individual bleeding points, are effective in the short term, and persistence with these methods is advocated rather than major surgery.

Severe bleeding from urinary conduits. A case report

Repeated, often severe, bleeding occurred from conduits constructed for urinary diversion in a young man. Ileum, sigmoid colon and part of the gastric antrum were successively utilized for diversion of urine. Histologic studies showed inflammatory changes within the conduit loops. The cause of this rare condition is unknown. Various measures to control the bleeding were unsuccessful.

Parastomal ileal conduit hemorrhage and portal hypertension

An analysis of six cases of parastomal ileal conduit hemorrhage in patients with portal hypertension is presented. The presence of coexisting esophageal varices, documented in only one of six cases (17%), suggest preferential retrograde portal flow through mesenteric venous (as opposed to coronary-azygos) collateral channels. Venous phase mesenteric angiography offers the best diagnostic specificity and provides inferential evidence regarding overall liver blood flow. Operative therapy should be based on assessment and understanding of the splanchnic circulatory derangements which accompany intrahepatic portal obstruction.