Brisk Hematochezia in Cirrhosis

Tom Couri

Case

A 61 year old male with a past medical history of alcohol-related cirrhosis complicated by esophageal variceal bleeding, ascites, and hepatocellular carcinoma presents with severe ascites. He had a therapeutic paracentesis with improvement in his ascites and underwent a surveillance EGD which showed large varices that were then banded. The following day, he developed tachycardia, hypotension, and hematochezia. A nasogastric tube was placed to suction without blood return.

What is the most likely etiology of the bleed?

Correct Answer:

Rectal varices

The most likely diagnosis for this patient is bleeding from rectal varices (RV). The patient is suffering from a brisk gastrointestinal bleed, however it is initially unclear if the bleeding is originating from the upper or lower gastrointestinal tract. While an esophageal variceal (EV) bleed is possible, EV banding the day prior, coupled with a negative nasogastric (NG) aspirate, makes this diagnosis less likely. Similarly, an EV band ulcer bleed and portal hypertensive gastropathy (PHG) bleed would also present with a positive NG aspirate, and these types of bleeds are less likely to present with hemodynamic instability. Bleeding from rectal varices is the best explanation for the patient’s clinical presentation. Read on to learn more about why this is the case and about the epidemiology and management of RV bleeding.

Epidemiology and Diagnosis of Rectal Variceal Bleeding

Rectal varices (RV) are dilated submocsal portosystemic collateral veins present at a minimum of four centimeters proximal to the anal verge. RV are common in patients with cirrhosis and portal hypertension, with an estimated incidence of 38%-56%. However, rectal variceal bleeding is rare, occurring in only 0.5%-5% of patients with RV. The gold standard for RV diagnosis is endoscopy. Although direct visualization with endoscopy is the most common method for diagnosing RV, endoscopic ultrasound has a higher accurary rate (85% vs 45%).

Figure 1 - Endoscopic view of rectal varices.

Taken from: Successful Treatment of Bleeding Rectal Varices with Occluded Antegrade Transvenous Obliteration. ACG Case Reports Journal 2018.

Figure 2 - Endoscopic ultrasound view of rectal varices.

Taken from: EUS-Guided Coiling of Rectal Varices. VideoGIE 2017.

Back to the case

The patient had continued hematochezia without melena or hematemesis, and a massive transfusion protocol was initiated. Due to refractory hypotension, the patient was transferred to the medical ICU and vasopressors were started. Because of the concern for RV bleeding, the patient was taken directly to the interventional radiology suite for further management. By this time, approximately twenty units of both packed red blood cells and fresh frozen plasma had been given, and the patient required five vasopressors for hemodynamic support.

Management of Rectal Variceal Bleeding

The cornerstones of RV bleeding management are medical, endoscopic, interventional radiology-based, and surgical. Standard medical management for portal hypertensive bleeding—resuscitation, gram-negative antibiotic coverage for infection prophylaxis, and a somatostatin analog such as octreotide to reduce portal pressures—are recommended. Endoscopic options for hemostasis include the following: cyanoacrylate injection, sclerotherapy injection, and band ligation. Cyanoacrylate carries a risk of embolization and sepsis. This risk can be minimized by coupling this method with EUS guided coil embolization. Risks of sclerotherapy also include embolization, and band ulcers can develop as a complication of banding.

Interventional radiology procedures for managing RV bleeding include the following: embolization, transjugular intra-hepatic portosystemic shunt (TIPS), and balloon-occluded retrograde transvenous obliteration (BRTO). Embolization can be performed solo or in combination with TIPS. While BRTO does not decrease portal pressures as TIPS does, benefits of BRTO over TIPS are that it is less invasive, can be performed in those with minimal hepatic reserve, and does not increase the risk of hepatic encephalopathy as TIPS does. BRTO can, however, cause worsening of esophageal varices by eliminating a shunt. Surgical management is often challenging due to the severe liver disease of affected patients. Portocaval shunt creation is one surgical option, although there is a reported 80% mortality within two months of this surgery. Other options include suture ligation or rectal variceal stapling; the latter has a higher reported success rate than the former.

Figure 3 - Therapeutic modalities for rectal variceal bleeding

BRTO: balloon-occluded retrograde transvenous obliteration, TIPS: transjugular intrahepatic portosystemic shunt.

Back to the case

The patient underwent emergent TIPS and embolization of actively bleeding rectal varices. Despite these interventions, he continued to have refractory shock and died.

Take Home Points :

  • Rectal varices are common in patients with cirrhosis and portal hypertension, however bleeding from rectal varices is rare
  • Rectal variceal bleeding should always be in the differential diagnosis for hematochezia in cirrhosis patients
  • Medical, endoscopic, interventional radiology-based, and surgical options exist for rectal variceal bleeding management

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