Rupture of Rectal Varices Treated With Endoscopic Variceal Ligation

Management options for rectal variceal bleeding in the setting of hepatic encephalopathy

Bleeding related to rectal varices associated with portal hypertension is rare but life-threatening, and requires prompt treatment. We reviewed the literature for patients with this complex presentation and current recommendations, and commented on a case at our institution of a 68-year-old man with Child-Pugh B alcoholic liver cirrhosis and hepatic encephalopathy who presented with profuse life-threatening rectal variceal bleeding. Treatment options for rectal varices in patients with hepatic encephalopathy were reviewed and a management algorithm was devised from current knowledge in the literature. We suggest endoscopic management, and if unsuccessful then to proceed to angioembolization and/or balloon-occluded retrograde transvenous obliteration, which may be used in conjunction with surgical management. The chosen therapeutic option may depend on the clinical condition of the patient, the cause of portal hypertension and clinical expertise or facilities available. Given that transjugular intra-hepatic portosystemic shunting is contraindicated in patients with hepatic encephalopathy, management of life-threatening rectal variceal bleeding should be multimodal.

A case of early colorectal cancer with rectal varices treated with endoscopic variceal ligation

Rectal varices are ectopic varices that occur in patients with portal hypertension and cause abrupt gastrointestinal bleeding. Endoscopic variceal ligation is a minimally invasive treatment used for patients with bleeding from rectal varices. Endoscopic treatment of colorectal tumors accompanied by rectal varices has been rarely reported. It is very important to control bleeding during treatment. The patient was a 76-year-old man who had a chief complaint of bloody stools. A flat-elevated-type neoplastic lesion measuring about 20 mm was found above the rectal varices. After performing endoscopic variceal ligation for rectal varices around the lesion, the lesion was resected en bloc by endoscopic submucosal dissection. Bleeding was controlled during the procedure; the patient was discharged 7 days after the endoscopic treatment, and there was no postoperative bleeding. Colonoscopy performed 90 days after the procedure showed scar formation in the wound area and no remnant lesion. The implementation of preoperative endoscopic variceal ligation enabled us to control bleeding during endoscopic treatment in a case of early colorectal cancer accompanied by rectal varices.

Circumferential stapled procedure for bleeding ano-rectal varices is an effective treatment--experience in nine patients

OBJECTIVE

The objective of this study was to demonstrate that stapled disruption of rectal varices is a feasible and suitable method of controlling bleeding varices.

METHOD

Patients known to have bleeding rectal varices secondary to liver failure were offered this procedure. All these patients had failed medical and endoscopic management. All nine patients underwent the procedure as an emergency, with the intention of controlling haemorrhage. The procedure was carried out under general anaesthetic by a colorectal surgeon experienced in using the stapled device for haemorrhoidectomy.

RESULTS

Nine patients underwent this procedure, with successful control of bleeding achieved in all. Follow-up period from 4 to 24 months revealed no further re-bleeding.

CONCLUSION

We conclude that stapled disruption of bleeding rectal varices in patients with known portal hypertension is a very useful and effective procedure when carried out by an experienced colorectal surgeon.

[Bleeding from rectal varices in a patient with severe decompensated cirrhosis: success of endoscopic band ligation. A case report and review of the literature]

In patients with cirrhosis, portal hypertension can be complicated by bleeding rectal varices. Treatment of bleeding rectal varices is not well established because clinical therapeutic trials are scarce in the literature and there are only a few case reports. In most cases, first line treatment is endoscopic (band ligation or sclerotherapy) and in case of failure or rebleeding, portosystemic shunts are the second line treatment. The indication of endoscopic treatment is not always easy in patients with cirrhosis and impaired liver function as well as major haemostatic problems. We report the case of a patient with severe decompensated cirrhosis and bleeding rectal varices who was successfully treated by endoscopic band ligation.