Management of parastomal variceal bleeding with endoscopic ultrasound-guided coiling and human thrombin/fibrinogen injection.

BACKGROUND AND AIMS: Parastomal varices are an uncommon but serious cause of gastrointestinal bleeding in patients with portal hypertension. Conventional treatments include surgical revision or interventional radiology embolization, but these may not be feasible in advanced disease. Endoscopic ultrasound (EUS)-guided therapy offers a minimally invasive alternative. We describe 2 cases using EUS-guided coiling and combined thrombin/fibrinogen injection for parastomal variceal bleeding.

METHODS

Two patients with colorectal cancer and prior liver metastases developed recurrent bleeding from parastomal varices despite conservative or interventional radiology management. Feeding vessels were identified by EUS, accessed with a 19-gauge needle, and treated with intravascular coil embolization followed by injection of thrombin/fibrinogen.

RESULTS

Both procedures were technically successful without intraprocedural adverse effects. Doppler imaging confirmed near-complete obliteration of variceal flow. One patient remained free of recurrence, whereas the second required repeat treatment 2.5 months later, at which time cyanoacrylate glue was selected for definitive hemostasis.

CONCLUSIONS

EUS-guided coiling with thrombin/fibrinogen injection appears to be a safe and effective option for achieving hemostasis in parastomal varices. Its minimally invasive nature and ability to directly target variceal inflow make it a promising alternative when conventional therapies are not feasible. Larger studies are needed to evaluate predictors of durable success and long-term outcomes.