Portal Hypertensive Enteropathy Presenting as Recurrent Large-Volume Urostomy Bleeding

Portal hypertension usually manifests with gastroesophageal varices, portal hypertensive gastropathy, ascites, and hepatic encephalopathy. Although stomal varices have been described in colostomies, ileostomies, and urostomies, bleeding portal hypertensive enteropathy (PHE) involving an ileal conduit urostomy is previously unreported. A 58-year-old man with bladder and prostate cancer status post-cystoprostatectomy with ileal conduit urostomy, obesity, chronic kidney disease, and metabolic dysfunction and alcohol-associated liver disease-related cirrhosis presented with multiple admissions for recurrent gross hematuria via urostomy secondary to stomal bleeding and anemia. He required multiple hospitalizations for blood transfusions. CT imaging demonstrated cirrhosis and peristomal varices, while portal venography confirmed a 12 mm Hg portal-systemic gradient. Endoscopy of the conduit showed mucosal congestion consistent with PHE. Multiple interventions, including embolosclerotherapy, transhepatic variceal embolization, and carvedilol, provided only temporary relief. A transjugular intrahepatic portosystemic shunt was performed and he did not experience any further stomal bleeding. This case highlights a unique presentation of PHE manifesting as recurrent large-volume urostomy bleeding, expanding the clinical spectrum of ectopic varices and PHE-related hemorrhage. Recognition of this entity is essential for timely diagnosis and multidisciplinary management.