Massive Recurrent Bleeding from Parastomal Caput MedusaeKey Clinical MessageParastomal variceal embolization is a safe, life-saving, minimally invasive method that stops bleeding in acute hemorrhages caused by parastomal variceal caput medusae, which usually develops in patients with comorbidities and liver failure. Procedure is a well-tolerated procedure in terms of treatment, and multiple interventions can be safely performed if necessary.  Key words: Parastomal hemorrhage, caput medusae, parastomal variceal embolization, raspberry appearanceCase presentationA 58-year-old man diagnosed with rectum-invading prostate adenocarcinoma, underwent en bloc radical prostatectomy and rectal resection in 2015, resulting in a permanent end colostomy. Eventually, he needed oncologic treatment as HBV and lung metastases caused portal hypertension and liver cirrhosis. He showed with acute parastomal variceal hemorrhage from caput medusae (Video 1).Abnormal radial vascular formations at the mucocutaneous interface in the parastomal area with diffuse purplish coloring (the traditional ”raspberry appearance”) and surrounding bruises were detected in his physical examination (Figure 1). The bleeding was not controlled by initial conservative techniques such suturing, cauterization, and pressure dressings. Parastomal varices forming caput medusae and draining into systemic veins were disclosed upon angiographic imaging following catheterization of the inferior mesenteric vein and contrast injection (Figure 2). Complete blockage and bleeding stop followed from selective catheterization and coil embolization of the feeding veins (Figure 3). Angioembolization was used to successfully treat the patient; strict outpatient department monitoring followed.  DiscussionParastomal variceal bleeding, including from caput medusae, is a rare but life-threatening sign of abnormal varices in people who have portal hypertension. Because of its unusual position and complicated pathophysiology, parastomal varices need to be managed by a team of specialists who take into account each patient’s liver function, other health problems, and level of bleeding. As a first step in treatment, local conservative means like direct pressure, suture ligation, cauterization, or the use of topical hemostatic agents are often used. Even though these can help stop bleeding temporarily, they rarely cure the problem and have a high rate of return, especially in cases of persistent portal hypertension [1].As shown in this instance, endovascular embolization has developed as a minimally invasive, safe, and efficient therapy. Using coils, glue, or sclerosants to occlude feeding arteries, embolization can be done transhepatic, transjugular, or retrograde. Patients at high risk for complications during surgery may benefit from its tailored treatment, quick hemostasis, and repeatability in recurring instances [2]. Transjugular intrahepatic portosystemic shunt (TIPS) might be considered to relieve portal system pressure in individuals with decompensated liver disease or recurrent bleeding despite embolization. Though it increases the risk of hepatic encephalopathy and procedural problems, TIPS can lower portal pressure worldwide. Generally, surgical choices—including stoma relocation or variceal ligation—are reserved for patients who are not candidates for interventional radiology or have failed less invasive treatments [3].Long-term follow-up and portal pressure control are still important given the high recurrence potential. Combining medical treatment—such as beta-blockers—with embolization might provide more rebleeding protection.References1. Strauss C, Sivakkolunthu M, Ayantunde AA. Recurrent and troublesome variceal bleeding from parastomal caput medusae. Korean J Gastroenterol. 2014;64(5):290-293. doi: 10.4166/kjg.2014.64.5.290.2. Todd A, Shekhar C, O’Rourke J, et al. Technical and clinical outcomes following EUS-guided thrombin injection and coil implantation for parastomal varices. BMJ Open Gastroenterol. 2023;10(1):e000819. doi: 10.1136/bmjgast-2021-000819.3. Kaczmarek DJ, Kupczyk P, Schultheiß M, et al. TIPS for the management of stomal variceal bleeding due to cirrhotic and non-cirrhotic portal hypertension. Z Gastroenterol. 2022;60(5):753-760. doi: 10.1055/a-1508-6446.Written informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.    Video 1. Acute parastomal variceal bleeding originating from caput medusae.Figure 1. Abnormal radial vascular formations at the parastomal mucocutaneous junction from caput medusae, with diffuse purplish discoloration (a classic “raspberry appearance”) and surrounding bruising.Figure 2. Angiographic imaging showing parastomal varices (black arrow) draining into systemic veins.Figure 3. After elective catheterization and selective coil embolization, post-embolization angiogram showing occlusion of feeding veins (white arrow).