CASE REPORT Bleeding from peristomal varices in a cirrhotic patient with ileal conduit: treatment with transjugular intrahepatic portocaval shunt (TIPS) Gianpaolo Carrafiello & Domenico Laganà & Andrea Giorgianni & Domenico Lumia & Monica Mangini & Edi Paragone & Carlo Fugazzola Received: 30 October 2006 / Accepted: 5 December 2006 / Published online: 10 January 2007 # Am Soc Emergency Radiol 2007 Abstract We report an unusual case of a 71-year-old man with liver cirrhosis who presented recurred bleedings from the stoma of the ileal conduit after radical cystoprostatec- tomy. The haemorrhages could not be treated by local measures, and a transjugular intrahepatic portocaval shunt was performed, displacing an endoprosthesis and a self- expandable stent. We highlight the role of TIPS to treat recurrent bleedings from the stoma in cirrhotic patients with ileal conduit and portal hypertension. Keywords TIPS . Varices . Stoma . Bleeding Introduction Peristomal varices represent ectopic portosystemic shunts, and their bleeding is a rare but well-known life-threatening complication in patients with severe portal hypertension [1]. The bleeding usually arises from enterostomal varices at the level of the mucocutaneous border of the stoma [2]. This complication was first reported by Resnick et al. [3] in 1968 who presented three cases. Different modalities of treatment can be considered: conservative local measures, such as sclerotherapy, but they are associated with high recurrence rates [4]; surgical shunting procedures that are not indicated in the high risk cirrhotic patients; transjugular intrahepatic portosystemic shunt (TIPS) with or without embolisation of varices that have become accepted today as the treatment of choice [2, 4]. We present a case report of the treatment of peristomal varices by TIPS, performed in emergency, in patients with ileal conduit. Case report A 71-year-old man underwent radical cystoprostatectomy and ileal conduit in 1990, for the treatment of transitional cell carcinoma of the bladder. The patient had a history of ethyltoxic liver cirrhosis and multifocal hepatocellular carcinoma with severe portal hypertension and oesophageal varices. In October 2003, the patient was admitted to our hospital with hypotension after massive haemorrhage from peristo- mal varices with 7.4 mg/dl of haemoglobin and transfusion of four units of red blood cells; the patients were then treated by ligation of a stomal vessel. Two weeks later, the patients were readmitted to our institution for recurrent haemorrhage, severe hypotension (80/55 mgHg) and 7.6 mg/dl of haemoglobin in spite of transfusion. TIPS was recommended. The procedure was performed in emergency setting in angiographic room under conscious sedation. The access route was the right internal jugular vein, and a Colapinto needle (Cook, Bloomington, IN, USA) was used to perform a “blind puncture” to enter the portal vein; prelim- inary portal venography showed the site of entrance in portal vein and retrograde filling of varices (Fig. 1); the shunt was performed between left hepatic vein and left portal branch. Because the site of entrance in portal vein was near to hepatic bifurcation of portal vein, a pre-procedural CT was not available to verify if bifurcation was intrahepatic or extrahepatic; the use of a stent graft (Wallgraft Endo- Emerg Radiol (2007) 13:341–343 DOI 10.1007/s10140-006-0564-y G. Carrafiello (*) : D. Laganà : A. Giorgianni : D. Lumia : M. Mangini : E. Paragone : C. Fugazzola Department of Radiology, University of Insubria, Viale Borri, 57, 21100 Varese, Italy e-mail: gcarraf@tin.it