What is the management approach for patients with rectal varices?

Management of Rectal Varices

The management of rectal varices requires a step-wise approach beginning with diagnostic evaluation, followed by initial stabilization measures, and then specific interventions based on bleeding severity, with endoscopic procedures as first-line treatment for active bleeding. 1, 2

Diagnostic Approach

• Ano-proctoscopy or flexible sigmoidoscopy should be used as first-line diagnostic tools for suspected bleeding rectal varices 1, 2
• 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, 2
• 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

Initial Management of Bleeding Rectal Varices

Resuscitation and Stabilization

• Provide intravenous fluid replacement and blood transfusions as necessary 1, 2
• Maintain hemoglobin levels >7 g/dL during resuscitation 1, 2
• Maintain mean arterial pressure >65 mmHg while avoiding fluid overload 1, 2
• Correct coagulopathy before any interventional procedures 1, 2
• Consider endorectal placement of a compression tube as a bridging maneuver to stabilize the patient or facilitate transfer to a tertiary hospital 2

Pharmacological Management

• Administer vasoactive drugs (terlipressin or octreotide) to reduce splanchnic blood flow and portal pressure 1, 2
• Provide a short course of prophylactic antibiotics 1, 2
• Use non-selective beta-adrenergic blockers for prevention/prophylaxis of first and recurrent variceal bleeding, but temporarily suspend them during acute bleeding 1, 2

Endoscopic Interventions

• Local endoscopic procedures should be used as first-line treatment to arrest bleeding where feasible 1, 2
• Endoscopic variceal ligation (EVL) is an effective option for treatment, with studies showing successful variceal obliteration and low recurrence rates at 5-year follow-up 1, 3
• Endoscopic injection sclerotherapy (EIS) can be considered, particularly for varices with multiple drainage vessels 4
• EUS-guided glue injection is another effective option for treatment 1, 2

Advanced Management for Refractory Bleeding

Interventional Radiology

• A step-up approach with radiological procedures is recommended when medical treatment and local procedures fail 1, 2
• Embolization via interventional radiological techniques should be used for short-term control of bleeding 1, 2
• Balloon-occluded retrograde transvenous obliteration (B-RTO) should be considered when single or two drainage vessels are identified 4
• 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, 2

Surgical Management

• Surgical procedures should be considered only after failure of medical treatment, local and radiological procedures 1, 2
• Avoid "per anal" suture ligation due to high risk of complications 2

Important Considerations and Pitfalls

• Prompt differentiation between hemorrhoids and rectal varices is crucial for appropriate management 5
• TIPS can be effective for controlling acute life-threatening bleeding but may lead to rapid decompensation of liver function and encephalopathy in high-risk patients 5
• Rectal variceal bleeding may have a relationship with previous treatment of esophageal varices, with 73% of patients with ruptured rectal varices having undergone prior esophageal variceal treatment 6
• Regular endoscopic surveillance is essential following successful treatment, as recurrence of rectal varices is possible 3
• A multidisciplinary approach involving hepatology specialists is essential, focusing on optimal control of underlying liver disease and portal hypertension 1