What is the management approach for patients with rectal varices?

Management of Rectal Varices

The management of rectal varices requires a multidisciplinary approach with early involvement of hepatology specialists, focusing on hemodynamic stabilization, endoscopic intervention, pharmacological therapy, and escalation to radiological or surgical procedures when necessary. 1

Initial Assessment and Diagnosis

• Perform focused medical history and complete physical examination, including digital rectal examination, to rule out other causes of lower gastrointestinal bleeding 1
• Check vital signs, hemoglobin, hematocrit, and coagulation parameters to evaluate bleeding severity 1
• Obtain blood typing and cross-matching in cases of severe bleeding 1
• Use ano-proctoscopy or flexible sigmoidoscopy as first-line diagnostic tools 1
• Consider EUS with color Doppler evaluation to better visualize the varices and assess blood flow velocity to predict bleeding risk 2
• Perform urgent colonoscopy (plus upper endoscopy) within 24 hours for patients with high-risk features or ongoing bleeding 1
• Consider full colonoscopy if there are risk factors for colorectal cancer or suspicion of a more proximal bleeding source 1

Non-Operative Management

Resuscitation and Stabilization

• Provide intravenous fluid replacement and blood transfusion if necessary 1
• Maintain hemoglobin levels >7 g/dL (4.5 mmol/L) during resuscitation and mean arterial pressure >65 mmHg, while avoiding fluid overload 1
• Correct coagulopathy before any interventional procedures 1, 3
• Consider endorectal placement of a compression tube as a bridging maneuver to stabilize the patient or facilitate transfer to a tertiary hospital 1

Pharmacological Management

• Use vasoactive drugs such as terlipressin or octreotide to reduce splanchnic blood flow and portal pressure 1
• Administer a short course of prophylactic antibiotics 1
• Consider non-selective beta-adrenergic blockers for prevention/prophylaxis of first and/or recurrent variceal bleeding, but temporarily suspend them during acute bleeding 1

Endoscopic Intervention

• Use local procedures as first-line treatment where feasible, including: 1, 2
  • Endoscopic variceal ligation
  • Endoscopic band ligation
  • Sclerotherapy
  • EUS-guided glue injection

Step-Up Approach for Refractory Bleeding

Interventional Radiology

• For patients with bleeding rectal varices and failure of medical treatment and local procedures, use a "step-up" approach with radiological procedures before considering surgery 1
• Consider embolization via interventional radiological techniques for short-term control of bleeding 1
• Use percutaneous transjugular intrahepatic portosystemic shunt (TIPS) to decompress the portal venous system and reduce rebleeding risk in patients with severe portal hypertension, if not contraindicated 1, 4

Surgical Management

• Consider surgical procedures only after failure of medical treatment, local and radiological procedures 1
• Avoid "per anal" suture ligation due to high risk of complications 1
• No specific recommendations can be made regarding Doppler-guided hemorrhoidal artery ligation and stapled anopexy based on available literature 1

Special Considerations

• TIPS may be effective for controlling life-threatening bleeding but can be associated with serious complications, including rapid decompensation of liver function and encephalopathy 5
• TIPS is contraindicated in patients with congestive heart failure; alternative interventional radiological approaches such as Gelfoam slurry embolization with coiling may be considered in such cases 6
• Distinguish rectal varices from hemorrhoids, as techniques for hemorrhoidal bleeding control can have disastrous results when applied to rectal varices 4
• Patients with rectal varices should be monitored closely for signs of rebleeding, as this is a common complication 7