Management of Rectal Varices
The management of rectal varices requires a step-up approach starting with endoscopic interventions for diagnosis and treatment, followed by pharmacological therapy, and escalating to radiological and surgical interventions when initial approaches fail. 1
Diagnostic Approach
- Ano-proctoscopy or flexible sigmoidoscopy should be used as the first-line diagnostic tool for suspected bleeding rectal varices 1
- Urgent colonoscopy (plus upper endoscopy) within 24 hours is indicated for patients with high-risk features or evidence of ongoing bleeding 1
- Full colonoscopy should be performed if the patient has risk factors for colorectal cancer or suspicion of a concomitant more proximal source of bleeding 1
- Endoscopic ultrasound (EUS) with color Doppler evaluation serves as a second-line diagnostic tool, especially for deep rectal varices or when diagnosis is uncertain 1
- Contrast-enhanced CT scan is recommended when bleeding site detection fails with endoscopy and EUS, or when EUS is unavailable 1
- MRI angiography should be considered for pregnant patients with failed ultrasound detection of bleeding site 1
Initial Management of Bleeding Rectal Varices
Non-operative Management
- A multidisciplinary approach involving hepatology specialists is essential, focusing on optimal control of comorbid conditions 1
- For mild bleeding:
- For severe bleeding:
Endoscopic Interventions
- Local endoscopic procedures should be used as first-line treatment to arrest bleeding where feasible 1
- Options include:
Pharmacological Management
- Non-selective beta-adrenergic blockers are recommended for prevention/prophylaxis of first and recurrent variceal bleeding 1
- Beta blockers should be temporarily suspended during acute bleeding 1
- Vasoactive drugs (terlipressin or octreotide) should be considered to reduce splanchnic blood flow and portal pressure 1
- A short course of prophylactic antibiotics is strongly recommended 1
Advanced Management for Refractory Bleeding
Radiological Interventions
- A step-up approach with radiological procedures is recommended when medical treatment and local procedures fail 1
- Embolization via interventional radiological techniques should be used for short-term control of bleeding 1
- Percutaneous transjugular intrahepatic portosystemic shunt (TIPS) should be considered for patients with severe portal hypertension to decompress the portal venous system and reduce rebleeding risk, if not contraindicated 1, 6
- Caution is warranted as TIPS may lead to rapid decompensation of liver function and encephalopathy in some patients 6
Surgical Management
- Surgical procedures should be considered when medical treatment, local and radiological procedures fail 1
- Per anal suture ligation is not recommended 1
Follow-up and Prevention
- Endoscopic surveillance is crucial as recurrence is possible 4
- Continued use of non-selective beta-blockers for prevention of recurrent bleeding is recommended 1
- Optimal management of underlying liver disease and portal hypertension is essential 1, 7
Common Pitfalls and Caveats
- Failure to differentiate between hemorrhoids and rectal varices can lead to inappropriate management 6
- Rectal varices may develop or worsen after treatment of esophageal varices 3
- Overestimation of thrombotic risk can lead to unnecessary bridging therapy, increasing bleeding risk 2
- TIPS, while effective for controlling acute bleeding, may precipitate hepatic encephalopathy and liver failure in patients with advanced cirrhosis 6