San Ysidro Health/Scripps Mercy Chula Vista Hospital San Diego, California
Introduction: Acute variceal hemorrhage is a gastrointestinal emergency and a major cause of death in cirrhotics. We present a rare case of rectal variceal hemorrhage causing clinically significant bleeding.
Case Description/Methods: A 38 year old with alcohol use disorder presented with jaundice and confusion. He was ill-appearing, unable to follow commands, with scleral icterus, abdominal distention with positive fluid wave and anasarca. He had a hemoglobin of 3.7 g/dL, platelet count of 100 K/mcL, creatinine of 1.9 mg/dL, total bilirubin of 36.3 mg/dL, lactate of 9.9 mmol/L, ammonia of 82 mcmol/L and INR of 4.3. Computed tomography of the abdomen and pelvis with contrast showed a cirrhotic appearing liver, portal venous hypertension, moderate ascites and mesenteric varices. He was transfused 2 units of packed red blood cells (pRBC) with improvement in hemoglobin to 7 and initiated on treatment for decompensated cirrhosis. Gastroenterology was consulted with esophagogastroduodenoscopy (EGD) finding grade D esophagitis without evidence of varices or ulcerations. Despite lactulose and rifaximin, his encephalopathy worsened and he was intubated for airway protection. His stool became increasingly saturated with blood and his hemoglobin continued to downtrend, requiring a total of 9 units of pRBCs over the course of 4 days. A repeat EGD found no varices. Colonoscopy was performed which revealed 5 tortuous bleeding rectal varices that were band ligated. Transfusion requirements dramatically decreased post-procedure.
Discussion: Due to rarity, there are no established guidelines for treatment of rectal varices as opposed to esophageal varices. Unlike bleeding gastroesophageal varices, no randomized control trials have shown proven benefit for use of vasoactive drugs such as octreotide in bleeding rectal varices. Management of rectal varices can include methods involving endoscopy, interventional radiology or surgery. One retrospective study showed that endoscopic injection sclerotherapy has greater efficacy compared to endoscopic band ligation with less rebleeding rate. However, another study showed endoscopic band ligation to be superior. Additional procedures such as transjugular intrahepatic portosystemic shunt with or without embolization and balloon-occluded retrograde transvenous obliteration have also demonstrated resolution of acute bleeding. Failure of these methods leads to surgical treatment such as suture ligation and porto-caval shunt. We achieved hemostasis with endoscopic variceal ligation.
