title: Transjugular intrahepatic porto-systemic shunt and variceal embolisation in the management of bleeding stomal varices.
abstract: OBJECTIVE
  Bleeding from stomal varices is uncommon. Local measures to control the bleeding offer short-lived control. Our experience with transjugular intrahepatic porto-systemic shunt (TIPS) and variceal embolisation is presented and appraised.
  
  
  METHODS
  Three patients presented with bleeding from stomal varices (Child-Pugh class B, n=2 and class C, n=1) in association with primary sclerosing cholangitis, autoimmune hepatitis and alcoholic liver disease. Local treatment measures including suture ligation, sclerotherapy and re-siting of the stoma achieved short-lived control. TIPS were inserted in all 3 patients, with embolisation of the stomal varices in 2.
  
  
  RESULTS
  The radiological interventions were uncomplicated and resulted in cessation of the bleeding in all patients. One of the patients has had no further bleeding at 12 months' follow-up post-TIPS insertion. The other two patients re-bled at 5 and 6 months post-TIPS insertion and were successfully managed by insertion of a second TIPS in one patient and by balloon dilatation of the TIPS in another. The former patient has had no re-bleeding at a further 8 months' follow-up, while the latter had re-bleeding at 12 months post-TIPS insertion and underwent liver transplantation.
  
  
  CONCLUSIONS
  Transjugular intrahepatic porto-systemic shunt with variceal embolisation offers an effective, minimally invasive management option in patients with bleeding stomal varices, and may be used as the primary mode of intervention in conjunction with medical therapy, and as the definitive therapy in patients unfit for surgery. TIPS and variceal embolisation do not preclude subsequent liver transplantation, and may be used during the acute situation as a bridge to transplantation.
authors.affiliation: Department of Surgery, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK.
authors.forename: Bassam
authors.initials: B
authors.lastname: Alkari
authors.forename: Nabeel M
authors.initials: NM
authors.lastname: Shaath
authors.forename: Yesar
authors.initials: Y
authors.lastname: El-Dhuwaib
authors.forename: Ali
authors.initials: A
authors.lastname: Aboutwerat
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Warnes
authors.forename: Nicholas
authors.initials: N
authors.lastname: Chalmers
authors.forename: Basil J
authors.initials: BJ
authors.lastname: Ammori
mesh_terms: D000328:Adult; D021721:Balloon Occlusion; D004932:Esophageal and Gastric Varices / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D006801:Humans; D008875:Middle Aged; D019168:Portasystemic Shunt, Transjugular Intrahepatic; D014057:Tomography, X-Ray Computed; D018608:Ultrasonography, Doppler