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Long-delayed gross hematuria due to portal hypertension in an alcoholic cirrhotic patient with ileal conduit urinary diversion
Fabrizio Dal Moro
,
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fabrizio.dalmoro@unipd.it

Correspondence and reprint request:
* Department of Surgical, Oncological and Gastroenterological Sciences. University of Padova. Padova, Italy
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="p0005" class="elsevierStylePara elsevierViewall">Peristomal varices in cirrhotic patients with ileal conduit urinary diversion after radical cystectomy represent ectopic portosystemic shunts&#46; Their bleeding is a very rare but life-threatening complication&#46; Many treatments have been proposed&#44; with various recurrence rates&#46;</p><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Case Report</span><p id="p0010" class="elsevierStylePara elsevierViewall">A 60-year-old man&#44; who had undergone cystoprostatectomy with ileal conduit urinary diversion for invasive bladder cancer 16 years previously &#40;1991&#41; and partial hepatectomy for hepatocellular carcinoma in chronic alcoholic cirrhosis 2 years later &#40;1993&#41;&#44; presented with episodes of massive spontaneous urostomal gross hematuria &#40;2007&#41;&#46;</p><p id="p0015" class="elsevierStylePara elsevierViewall">The patient had been treated with vasoactive drugs &#40;beta-blocker therapy&#41; and sclerotherapy &#40;three times from 2002 and 2003&#41; for esophageal variceal bleeding due to varices&#46; The severity of cirrhosis at the moment of bleeding was Child-Pugh class B7 and MELD score 14&#44; respectively&#44; with a hepatic venous gradient &#40;HVPG&#41; of 18&#46;1 mm&#47;Hg&#46;</p><p id="p0020" class="elsevierStylePara elsevierViewall">CT angiography performed during urostomal bleeding revealed large dilation of the portal vein and superior mesenteric vein&#44; with a rich system of collateral veins at the level of the ileal conduit &#40;<a class="elsevierStyleCrossRef" href="#f0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><p id="p0025" class="elsevierStylePara elsevierViewall">Due to the severity of acute bleeding&#44; the patient was successfully treated with an emergency transjugular intrahepatic portosystemic shunt &#40;2007&#41;&#46; He survived without episodes of bleeding for 5 years before his death from neoplastic causes in 2012&#46;</p><p id="p0030" class="elsevierStylePara elsevierViewall">The initial factor in the pathophysiology of portal hypertension is known to be increased vascular resistance to portal blood flow&#46; The increase in both blood pressure and flow in the portal veins explains why portal hypertension exists&#44; despite the formation of an extensive network of portosystemic collaterals&#46; Increased portal pressure contributes to the formation of ectopic varices&#46; Fewer than 5&#37; of patients with portal hypertension present intestinal varices&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Rupture and consequent hemorrhage occur when the tension of the varices exceeds the elastic limits of the variceal wall&#46; The development of ectopic varices and their further bleeding&#44; due to cirrhosis and portal hypertension&#44; are a rare cause of hematuria in patients with surgically augmented bladder volume or urinary diversion&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="p0035" class="elsevierStylePara elsevierViewall">Bleeding stomal varices in patients with ileostomy and portal hypertension were described by Resnick in 1968&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> but the first description of variceal bleeding in an urinary ileal conduit was reported only in 1975 by Foulkes and Wallace&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="p0040" class="elsevierStylePara elsevierViewall">One review reported that the average time from the creation of ileal conduit urinary diversion to the development of ectopic varices and consequent bleeding is 38 months&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The period of 167 months with urinary ileal conduit before stomal variceal bleeding recorded in our case is&#44; to our knowledge&#44; the longest delay of a similar complication reported in the literature&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">Proper diagnosis requires careful inspection of the muco-cutaneous region of the stoma and endoscopic examination of the ileal conduit&#46; However&#44; reconstruction of portal-phase CT angiograms enhances perception of the courses and anatomic relationships of varices&#46; In our case&#44; by precisely demonstrating the courses of ileal varices&#44; CT angiography allows the surgeon to plan the operative approach&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="p0050" class="elsevierStylePara elsevierViewall">Emergency treatment of bleeding may involve several methods&#44; such as local compression &#40;i&#46;e&#46;&#44; a Foley catheter is introduced into the ileal conduit&#41; or sclerotherapy&#46; In our case&#44; because of the severity of acute bleeding&#44; a transjugular intrahepatic portosystemic shunt procedure was successfully emplaced&#46;</p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Financial Support&#47;Conflict of Interest</span><p id="p0055" class="elsevierStylePara elsevierViewall">I have no financial support and no conflict of interest to disclose&#46;</p></span></span>"
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ISSN: 16652681
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos