Abstract
In the setting of portal hypertension, intractable bleeding from anorectal varices is a rare occurrence. In this review, clinical presentation and management of this dilemma are presented in a case-based fashion. Bleeding may occur in the absence of prior history of cirrhosis or gastroesophageal varices and measurement of hepatic venous pressure gradient and liver biopsy could help to establish the diagnosis. Successful treatment outcome necessitates tailoring treatment to the patient’s anatomy and imaging findings. A multidisciplinary algorithmic approach is also proposed to aid clinicians in this regard.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Chawla Y, Dilawari JB (1991) Anorectal varices–their frequency in cirrhotic and non-cirrhotic portal hypertension. Gut 32 (3):309-311
Vangeli M, Patch D, Terreni N, Tibballs J, Watkinson A, Davies N, Burroughs AK (2004) Bleeding ectopic varices–treatment with transjugular intrahepatic porto-systemic shunt (TIPS) and embolisation. J Hepatol 41 (4):560-566. https://doi.org/10.1016/j.jhep.2004.06.024
Dariushnia SR, Haskal ZJ, Midia M, Martin LG, Walker TG, Kalva SP, Clark TW, Ganguli S, Krishnamurthy V, Saiter CK, Nikolic B, Society of Interventional Radiology Standards of Practice C (2016) Quality Improvement Guidelines for Transjugular Intrahepatic Portosystemic Shunts. J Vasc Interv Radiol 27 (1):1-7. https://doi.org/10.1016/j.jvir.2015.09.018
Grace ND (1994) The side-to-side portacaval shunt revisited. The New England journal of medicine 330 (3):208-209. https://doi.org/10.1056/NEJM199401203300312
Sakib SM, Kobayashi K, Jawed M (2015) Potential Pitfalls in Transjugular Portosystemic Shunt Placement for Bleeding Rectal Varices. Case Rep Gastroenterol 9 (2):296-301. https://doi.org/10.1159/000439164
Hosking SW, Smart HL, Johnson AG, Triger DR (1989) Anorectal varices, haemorrhoids, and portal hypertension. Lancet 1 (8634):349-352
Goenka MK, Kochhar R, Nagi B, Mehta SK (1991) Rectosigmoid varices and other mucosal changes in patients with portal hypertension. The American journal of gastroenterology 86 (9):1185-1189
Norton ID, Andrews JC, Kamath PS (1998) Management of ectopic varices. Hepatology 28 (4):1154-1158. https://doi.org/10.1002/hep.510280434
Al Khalloufi K, Laiyemo AO (2015) Management of rectal varices in portal hypertension. World J Hepatol 7 (30):2992-2998. https://doi.org/10.4254/wjh.v7.i30.2992
Philips CA, Augustine P (2017) Endoscopic Ultrasound-Guided Management of Bleeding Rectal Varices. ACG Case Rep J 4:e101. https://doi.org/10.14309/crj.2017.101
Sato T, Yamazaki K, Akaike J, Toyota J, Karino Y, Ohmura T (2010) Retrospective analysis of endoscopic injection sclerotherapy for rectal varices compared with band ligation. Clin Exp Gastroenterol 3:159-163. https://doi.org/10.2147/CEG.S15401
Weilert F, Shah JN, Marson FP, Binmoeller KF (2012) EUS-guided coil and glue for bleeding rectal varix. Gastrointest Endosc 76 (4):915-916. https://doi.org/10.1016/j.gie.2011.09.027
Seewald S, Ang TL, Imazu H, Naga M, Omar S, Groth S, Seitz U, Zhong Y, Thonke F, Soehendra N (2008) A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos). Gastrointest Endosc 68 (3):447-454. https://doi.org/10.1016/j.gie.2008.02.050
Kaul AK, Skaife PG (2009) Circumferential stapled procedure for bleeding ano-rectal varices is an effective treatment–experience in nine patients. Colorectal Dis 11 (4):420-423. https://doi.org/10.1111/j.1463-1318.2008.01616.x
Botterill ID, Jayne DG, Snelling AP, Ambrose NS (2002) Correction of symptomatic ano-rectal varices with circumferential stapled anoplasty. Colorectal Dis 4 (3):217. https://doi.org/10.1046/j.1463-1318.2002.00343.x
Boyer TD, Haskal ZJ, American Association for the Study of Liver D (2010) The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the Management of Portal Hypertension: update 2009. Hepatology 51 (1):306. https://doi.org/10.1002/hep.23383
Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J (2017) Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 65 (1):310-335. https://doi.org/10.1002/hep.28906
Riggio O, Angeloni S, Salvatori FM, De Santis A, Cerini F, Farcomeni A, Attili AF, Merli M (2008) Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts. The American journal of gastroenterology 103 (11):2738-2746. https://doi.org/10.1111/j.1572-0241.2008.02102.x
Sanyal AJ, Freedman AM, Luketic VA, Purdum PP, 3rd, Shiffman ML, Cole PE, Tisnado J, Simmons S (1997) Transjugular intrahepatic portosystemic shunts compared with endoscopic sclerotherapy for the prevention of recurrent variceal hemorrhage. A randomized, controlled trial. Ann Intern Med 126 (11):849-857
Merli M, Valeriano V, Funaro S, Attili AF, Masini A, Efrati C, De CS, Riggio O (2002) Modifications of cardiac function in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt (TIPS). The American journal of gastroenterology 97 (1):142-148. https://doi.org/10.1111/j.1572-0241.2002.05438.x
Ono Y, Kariya S, Nakatani M, Yoshida R, Kono Y, Kan N, Ueno Y, Komemushi A, Tanigawa N (2015) Balloon-Occluded Antegrade Transvenous Sclerotherapy to Treat Rectal Varices: A Direct Puncture Approach to the Superior Rectal Vein Through the Greater Sciatic Foramen Under CT Fluoroscopy Guidance. Cardiovasc Intervent Radiol 38 (5):1320-1324. https://doi.org/10.1007/s00270-015-1174-4
Tradi F, Louis G, Giorgi R, Mege D, Bartoli JM, Sielezneff I, Vidal V (2018) Embolization of the Superior Rectal Arteries for Hemorrhoidal Disease: Prospective Results in 25 Patients. J Vasc Interv Radiol 29 (6):884-892 e881. https://doi.org/10.1016/j.jvir.2018.01.778
Funding
No external funding used to perform this cased-based review paper.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
Authors have no conflicting interests to disclose.
Ethical approval
This review paper is approved by institutional review board. This work is original, follows all ethical standards, and has been read and approved by all authors. All procedures performed in patients were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all the patients included in current report.
Consent for publication
The Authors grants the Publisher the license of the full copyright for this contribution. The enclosed manuscript is not under consideration for publication in any other journal.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Rhanemai-Azar, A.A., Rajdev, M., Ismail, M. et al. Role of interventional radiology in intractable bleeding rectal varices. Abdom Radiol 46, 1163–1170 (2021). https://doi.org/10.1007/s00261-020-02746-6
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00261-020-02746-6