Treatment of bleeding rectal varices with transumbilical venous obliteration of the inferior mesenteric vein. Surg Laparosc Endosc Percutan Tech. 2013;23:e134-e137. [PMID: 23752023 DOI: 10.1097/sle.0b013e31828031ec]

Expert consensus on emergency procedures for portal hypertension bleeding (2022)

Expert consensus proposes an emergency treatment protocol for portal hypertension bleeding. Herein, the emergency treatment procedures, which include first aid, medical, interventional, and surgical treatments, are described. In addition, the indications, contraindications, operating norms, precautions, and prevention of complications of portal hypertension are described to optimize the first aid process.

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.

Percutaneous Transhepatic Embolization of Bleeding Rectal Varices Using A New Embolic And Sclerotic Mixture Augmented By Amplatzer Vascular Plug 2

We report a case of 59-year-old female with non-alcoholic-steato-hepatitis (NASH) induced cirrhosis, who presented with hematochezia. The patient had a history of bleeding esophageal varices treated with endoscopic variceal ligation (EVL). Colonoscopy showed large rectal varices which were the source of her lower gastrointestinal bleeding (LGIB). Since endoscopic treatment for LGIB are limited, and because the patient had portal vein thrombosis which contraindicated transjugular intrahepatic portosystemic shunt (TIPS), we performed percutaneous transhepatic embolization of her rectal varices using a new mixture of embolic and sclerotic agents, followed by Amplatzer plug 2 (AVP 2). To our knowledge, the use of this new mixture with the AVP 2 in the rectal varices treatment has not been previously published in literature. Our case provides an alternative treatment modality that can be used for rectal varices treatment, when TIPS and endoscopic management fails or is contraindicated.

Successful hemostasis of intractable rectal variceal bleeding using variceal embolization

Portal hypertension causes portosystemic shunting along the gastrointestinal tract, resulting in gastrointestinal varices. Rectal varices and their bleeding is a rare complication, but it can be fatal without appropriate treatment. However, because of its rarity, no established treatment strategy is yet available. In the setting of intractable rectal variceal bleeding, a transjugular intravenous portosystemic shunt can be a treatment of choice to enable portal decompression and thus achieve hemostasis. However, in the case of recurrent rectal variceal bleeding despite successful transjugular intravenous portosystemic shunt, alternative measures to control bleeding are required. Here, we report on a patient with liver cirrhosis who experienced recurrent rectal variceal bleeding even after successful transjugular intravenous portosystemic shunt and was successfully treated with variceal embolization.

Gastric and ectopic varices

Although often considered together, gastric and ectopic varices represent complications of a heterogeneous group of underlying diseases. Commonly, these are known to arise in patients with cirrhosis secondary to portal hypertension; however, they also arise in patients with noncirrhotic portal hypertension, most often secondary to venous thrombosis of the portal venous system. One of the key initial assessments is to define the underlying condition leading to the formation of these portal-collateral pathways to guide management. In the authors' experience, these patients can be grouped into distinct although sometimes overlapping conditions, which can provide a helpful conceptual basis of management.