Ileal Conduit Peristomal Varices Treated via Percutaneous Transhepatic Embolization: A Case Report

The development of ectopic varices is a well-documented but relatively rare consequence of portal hypertension. While the majority of portosystemic shunting in cirrhotic patients occurs at the gastroesophageal junction, some patients will develop varices in ectopic sites, like peristomal varices, which are a unique subset of ectopic varices. In this specific case, the patient's history of a Bricker ileal conduit (a urinary diversion created from a segment of the ileum) created a surgical interface between the portal-drained mesenteric circulation and the systemic venous circulation of the abdominal wall. When portal hypertension arises - in this patient due to chronic liver disease and hepatocellular carcinoma - the pressure gradient forces blood through these small collateral vessels. Over time, these vessels dilate, leading to the formation of high-pressure varices just beneath the thin stomal mucosa. This results in the clinical sign known as the "caput medusae" of the stoma, characterized by a bluish or purple hue. These vessels are extremely fragile, and even minor trauma from a stoma appliance can trigger "voluminous" and life-threatening hemorrhage. Because of the high mortality rate associated with these bleeds, treatment must be immediate and definitive. Peristomal variceal management can range from conservative therapy to surgical and minimally invasive therapies.