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Life-threatening bleeding from peristomal varices after cystoprostatectomy: multimodal approach in a cirrhotic, encephalopathic patient with severe portal hypertension.

Staubli SE, Gramann T, Schwab C, Semela D, Hechelhammer L, Engeler DS, Schmid HP, Abt D, Mordasini L - Case Rep Urol (2015)

Bottom Line: CT imaging showed liver cirrhosis with a prominent portosystemic shunt leading to massively enlarged peristomal varices.Medical therapy with lactulose and the nonselective beta-blocker carvedilol was initiated to treat HE and portal hypertension.In a second step, the portosystemic shunt was percutaneously embolized.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Cantonal Hospital St. Gallen, 9007 St. Gallen, Switzerland.

ABSTRACT
The bleeding of peristomal varices due to a portosystemic shunt is rare but potentially life-threatening in cirrhotic patients with portal hypertension. The scarce case reports in the literature recommend transjugular intrahepatic portosystemic shunt (TIPS) to prevent further bleeding. We report on a 72-year-old man who was referred to our hospital because of life-threatening bleeding from peristomal varices, three years after radical cystoprostatectomy for invasive bladder cancer. CT imaging showed liver cirrhosis with a prominent portosystemic shunt leading to massively enlarged peristomal varices. TIPS was taken into consideration, but not possible due to hepatic encephalopathy (HE). Medical therapy with lactulose and the nonselective beta-blocker carvedilol was initiated to treat HE and portal hypertension. In a second step, the portosystemic shunt was percutaneously embolized. Here, we present a multimodal approach to treat intractable bleeding from peristomal varices in a patient with ileal conduit urinary diversion, not suitable for TIPS.

No MeSH data available.


Related in: MedlinePlus

Computed tomography 3D reconstruction illustrating the portosystemic shunt.
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Related In: Results  -  Collection


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fig1: Computed tomography 3D reconstruction illustrating the portosystemic shunt.

Mentions: CT imaging showed features of liver cirrhosis with a prominent portosystemic shunt (Figure 1), leading to massively enlarged peristomal varices and excluded upper urinary tract bleeding. TIPS was taken into consideration as a secondary prophylaxis to prevent rebleeding. However, neurologic assessment with connect-the-numbers test (Figure 2) revealed clinically relevant HE, making the patient not suitable for TIPS. Medical therapy with lactulose and the nonselective beta-blocker carvedilol was initiated to treat HE and portal venous hypertension, respectively. In a second step, the portosystemic shunt was percutaneously embolized with a combination of coils and histoacryl/lipiodol (Figure 3). Intravenous manometric measurement confirmed substantial portal hypertension with a portoatrial pressure gradient of 15 mmHg (normal 3–9 mmHg) before embolization.


Life-threatening bleeding from peristomal varices after cystoprostatectomy: multimodal approach in a cirrhotic, encephalopathic patient with severe portal hypertension.

Staubli SE, Gramann T, Schwab C, Semela D, Hechelhammer L, Engeler DS, Schmid HP, Abt D, Mordasini L - Case Rep Urol (2015)

Computed tomography 3D reconstruction illustrating the portosystemic shunt.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4325549&req=5

fig1: Computed tomography 3D reconstruction illustrating the portosystemic shunt.
Mentions: CT imaging showed features of liver cirrhosis with a prominent portosystemic shunt (Figure 1), leading to massively enlarged peristomal varices and excluded upper urinary tract bleeding. TIPS was taken into consideration as a secondary prophylaxis to prevent rebleeding. However, neurologic assessment with connect-the-numbers test (Figure 2) revealed clinically relevant HE, making the patient not suitable for TIPS. Medical therapy with lactulose and the nonselective beta-blocker carvedilol was initiated to treat HE and portal venous hypertension, respectively. In a second step, the portosystemic shunt was percutaneously embolized with a combination of coils and histoacryl/lipiodol (Figure 3). Intravenous manometric measurement confirmed substantial portal hypertension with a portoatrial pressure gradient of 15 mmHg (normal 3–9 mmHg) before embolization.

Bottom Line: CT imaging showed liver cirrhosis with a prominent portosystemic shunt leading to massively enlarged peristomal varices.Medical therapy with lactulose and the nonselective beta-blocker carvedilol was initiated to treat HE and portal hypertension.In a second step, the portosystemic shunt was percutaneously embolized.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Cantonal Hospital St. Gallen, 9007 St. Gallen, Switzerland.

ABSTRACT
The bleeding of peristomal varices due to a portosystemic shunt is rare but potentially life-threatening in cirrhotic patients with portal hypertension. The scarce case reports in the literature recommend transjugular intrahepatic portosystemic shunt (TIPS) to prevent further bleeding. We report on a 72-year-old man who was referred to our hospital because of life-threatening bleeding from peristomal varices, three years after radical cystoprostatectomy for invasive bladder cancer. CT imaging showed liver cirrhosis with a prominent portosystemic shunt leading to massively enlarged peristomal varices. TIPS was taken into consideration, but not possible due to hepatic encephalopathy (HE). Medical therapy with lactulose and the nonselective beta-blocker carvedilol was initiated to treat HE and portal hypertension. In a second step, the portosystemic shunt was percutaneously embolized. Here, we present a multimodal approach to treat intractable bleeding from peristomal varices in a patient with ileal conduit urinary diversion, not suitable for TIPS.

No MeSH data available.


Related in: MedlinePlus