What is the management approach for colonic varices?

Management of Colonic Varices

The management of colonic varices requires a multidisciplinary approach with a step-up treatment strategy, starting with medical management and progressing to endoscopic, radiological, and surgical interventions as needed based on bleeding severity and response to treatment. 1

Diagnosis

• Ano-proctoscopy or flexible sigmoidoscopy should be used as first-line diagnostic tools for suspected bleeding colonic varices 1
• Urgent colonoscopy within 24 hours is indicated for patients with high-risk features or ongoing bleeding 1, 2
• Full colonoscopy should be performed to rule out colorectal cancer (2.4-11% risk) or other proximal bleeding sources 2
• Upper endoscopy should be considered as up to 15% of patients with serious hematochezia have an upper GI bleeding source 2
• Endoscopic ultrasound with color Doppler can help distinguish colonic varices from hemorrhoids and assess bleeding risk 1, 3

Initial Management of Bleeding Colonic Varices

Resuscitation and Medical Management

• Ensure hemodynamic stability with intravenous fluid replacement and blood transfusions as needed 2
• Maintain hemoglobin level >7 g/dL during resuscitation and mean arterial pressure >65 mmHg while avoiding fluid overload 2
• Correct coagulopathy promptly 2
• Administer a short course of prophylactic antibiotics (strong recommendation) 2
• Consider vasoactive drugs such as terlipressin or octreotide to reduce splanchnic blood flow and portal pressure 2
• Temporarily suspend beta-blockers during acute bleeding episodes 2

Endoscopic Management

• Local endoscopic procedures should be used as first-line treatment to arrest bleeding where feasible 2
• Endoscopic band ligation can be effective for accessible colonic varices 1, 4
• Endoscopic injection sclerotherapy may be more effective than band ligation for active bleeding with lower rebleeding rates 3
• Consider endorectal placement of a compression tube as a bridging maneuver to stabilize the patient or allow transfer to a tertiary hospital 2

Advanced Management for Refractory Bleeding

Radiological Interventions

• For bleeding uncontrolled by medical and endoscopic measures, employ radiological interventions 2
• Embolization via interventional radiological techniques should be used for short-term control of bleeding 2
• Transjugular intrahepatic portosystemic shunt (TIPS) is recommended for patients with severe portal hypertension to decompress the portal venous system and reduce rebleeding risk 2, 5
• Balloon-occluded retrograde transvenous obliteration (BRTO) is an emerging alternative to TIPS, particularly effective for gastric varices but also applicable to rectal varices 2, 3

Surgical Management

• Consider surgical intervention only after failure of medical, endoscopic, and radiological approaches 2
• Avoid "per anal" suture ligation due to poor outcomes 2
• Historical surgical approaches included inferior mesenteric vein occlusion and porto-caval shunt surgery, but these have largely been replaced by less invasive options 2

Prevention of Recurrent Bleeding

• Non-selective beta-adrenergic blockers are recommended for prevention of first and recurrent variceal bleeding 2, 1
• Optimal management of underlying liver disease and portal hypertension is essential 1, 3

Special Considerations

• Mortality rates can be as high as 80% within 2 months of bleeding for patients with liver cirrhosis and bleeding anorectal varices 2
• Idiopathic colonic varices (without portal hypertension) are rare but may require different management approaches, including surgery in young patients with low comorbidity 6
• Isolated colonic varices may occur due to localized causes such as pancreatic cancer involving mesenteric vessels, requiring tailored management 7