Hematuria can be caused by a variety of conditions, including cancer, infections, and calculi. We recently treated a patient with an ileal conduit and cirrhosis, who had hematuria due to ileal varices and who eventually required treatment with a transjugular intrahepatic portosystemic shunt.
A 66-year-old woman with a history of hepatitis C reported a four-month history of intermittent hematuria in her ileal conduit. Four years earlier, she had undergone a cystectomy and placement of an ileal conduit for bladder carcinoma. The patient’s laboratory values on admission included a hemoglobin level of 6.7 g per deciliter, a platelet count of 141,000 per cubic millimeter, and a prothrombin time of 16.1 seconds. A cystoscope was passed into the ileal conduit, and the mucosa appeared normal. A computed tomographic scan of the abdomen and pelvis showed a small nodular liver and multiple varices in the anterior abdominal wall, with a large varix adjacent to the ileal stoma. The peristomal ileal varix was thought to be the most likely cause of the hematuria.
The patient was treated with propranolol and octreotide but continued to have hematuria, requiring the transfusion of one to two units of packed red cells per day. Because of the persistent bleeding, a transjugular intrahepatic portosystemic shunt was placed with the use of standard techniques. The hematuria stopped immediately thereafter, and the patient has had no further bleeding during six months of follow-up.
In patients with portal hypertension, bleeding can occur from so-called ectopic varices at the sites of previous operations.1,2 The treatment of these varices with a transjugular intrahepatic portosystemic shunt has been reported,3,4 although to our knowledge, the use of this shunt specifically to treat hematuria has not been described. Physicians should consider this unusual cause of hematuria, even in patients such as ours, who have not had other complications of cirrhosis.
- 4Medina CA, Caridi JG, Wajsman Z. Massive bleeding from ileal conduit peristomal varices: successful treatment with the transjugular intrahepatic portosystemic shunt. J Urol 1998;159:200-201
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- 1William H, TuDebbie, ChaoHarcharan, Gill. (2008) Gross hematuria from an ileal conduit as a first presentation of portal hypertension. Nature Clinical Practice Urology 5, 569-573
David M. Felig, M.D.
David P. Bleeker, M.D.
John S. DeMeritt, M.D.
Hackensack University Medical Center, Hackensack, NJ 07601
New England Journal of Medicine March 22, 2001; 344:939