Introduction: Rectal varices are abnormally dilated collateral vessels that may occur from systemic portal hypertension. The endoscopic management of bleeding rectal varix is often challenging; endoscopic band ligation has limited efficacy, and patients are often unsuitable for interventional radiology guided procedures and for surgical ligation. Our group has previously reported positive results of EUS-guided injection of coils and absorbable gelatin sponge (AGS; “Gelfoam”) for treatment of bleeding gastric varices. Herewe present a case series of endoscopic ultrasound (EUS) guided coil embolization combined with AGS for the management of bleeding rectal varices.
Case Description/Methods: Four cases of bleeding rectal varices were successfully treated with EUS guided coil embolization and Gelfoambetween 10/2018 and 3/2022 at a single tertiary center. Patient demographic and procedure characteristics are listed in Table 1. All 4 cases (100%) presented with active lower GI bleeding, with the rectal varices marked as the most likely etiology. Average age was 67, 3/4 (75%) were female, and mean MELD-Na score was 10. One patient required 3 units of pRBC transfusion prior to lower EUS.
Following multidisciplinary discussion with hepatology, interventional radiology, and surgery, it was decided to pursue endoscopic therapy in all 4 cases. All cases underwent EUS-guided puncture of rectal varices (specifically targeting perforator veins) with a 22G FNA needle to serially deploy 0.018” Nester Embolization Coils (Cook Medical, Bloomington, IN) of length ranging from 7-14cm total. Absorbable gelatin sponge (Gelfoam) was then injected as a liquid slurry for hemostatic reinforcement following coil embolization. All cases (100%) achieved technical success with successful coil and AGS injection, along with EUS confirmation of significant and immediate diminution of Doppler flow in the rectal varices. None of the procedures reported procedural-related adverse events. One patient had follow-up EUS at 1 month that demonstrated both endoscopic and sonographic evidence of obliteration of rectal varices.
Discussion: EUS guided coil embolization combined with an absorbable hemostatic gelatin sponge appears to be a safe and efficacious treatment option for bleeding rectal varices.
