What is the assessment and management approach for patients with colonic varices and anemia?

Assessment and Management of Colonic Varices with Anemia

Patients with colonic varices and anemia require prompt diagnosis and management focused on controlling bleeding, correcting anemia, and addressing the underlying cause of portal hypertension.

Diagnostic Approach

Initial Assessment

• Complete blood count, CRP, serum ferritin, and transferrin saturation are minimum requirements to detect anemia and determine its severity 1
• Evaluate inflammatory markers as inflammation affects ferritin interpretation - in inflammation, ferritin <100 μg/L (rather than <15 μg/L) may indicate iron deficiency 1
• Transferrin saturation <16% with ferritin between 30-100 μg/L in inflammatory states suggests iron deficiency 1

Endoscopic Evaluation

• Upper endoscopy should be performed in all cases where a clear diagnosis of bleeding colonic varices is not established, as up to 15% of patients with serious hematochezia have an upper GI source 1
• Colonoscopy is essential for diagnosis of colonic varices, which appear as tortuous dilated submucosal veins 2
• Small bowel biopsies should be taken during endoscopy to exclude other causes of anemia such as celiac disease 1

Additional Investigations

• Consider CT angiography to evaluate the extent of portosystemic collaterals and identify the feeding vessels of colonic varices 3
• Mesenteric angiography may be valuable in transfusion-dependent anemia for demonstrating vascular malformations 1

Management of Anemia

Iron Supplementation

• Iron supplementation should be initiated when iron deficiency anemia is present 1
• Options include oral iron (ferrous sulfate 200 mg three times daily) or intravenous iron 1
• In patients with inflammatory bowel disease or ongoing bleeding, IV iron may be preferred as oral iron can exacerbate gastrointestinal symptoms 1
• Continue iron supplementation for three months after correction of anemia to replenish iron stores 1

Blood Transfusion

• In patients with severe bleeding, maintain hemoglobin level >7 g/dL (4.5 mmol/L) during resuscitation 1
• Avoid fluid overload which may exacerbate portal hypertension and increase bleeding risk 1

Management of Bleeding Colonic Varices

Non-operative Management

• For mild bleeding: intravenous fluid replacement, blood transfusion if necessary, correction of coagulopathy, and optimal medication for portal hypertension 1
• Consider endorectal placement of a compression tube as a temporary bridging maneuver to stabilize the patient 1

Endoscopic Management

• Endoscopic therapy should be considered for patients with high-risk features or evidence of ongoing bleeding within 24 hours of presentation 1
• Multiple endoscopic techniques have been reported for controlling acute bleeding from varices 1

Advanced Interventions

• Balloon-occluded retrograde transvenous obliteration (BRTO) may be considered for colonic varices when traditional techniques are unsuccessful or contraindicated 3
• Transjugular intrahepatic portosystemic shunt (TIPS) insertion is an option for reducing portal pressure 3
• In medically intractable cases with recurrent hematochezia, surgical resection of the affected colonic segment may be necessary 2, 4

Follow-up

• Once hemoglobin is normalized, monitor at three-monthly intervals for one year and then after a further year 1
• Additional iron supplementation should be given if hemoglobin or MCV falls below normal 1
• Regular endoscopic surveillance may be necessary in patients with portal hypertension 1

Special Considerations

• Multidisciplinary management involving hepatology specialists is recommended for patients with portal hypertension 1
• Colonic varices can be idiopathic (rare) or secondary to portal hypertension (most common) 2, 5
• Cecal varices may present with anemia rather than massive lower GI bleeding 5