What is the best treatment approach for a patient with rectal varices, likely due to liver disease or portal hypertension, to prevent bleeding and other complications?

Treatment of Rectal Varices

Rectal varices require a stepwise treatment approach starting with multidisciplinary management involving hepatology, followed by endoscopic intervention for bleeding, vasoactive drugs and antibiotics, then escalating to interventional radiology (TIPS or embolization) if initial measures fail, with surgery reserved as a last resort. 1

Initial Assessment and Resuscitation

Diagnostic Approach

• Perform ano-proctoscopy or flexible sigmoidoscopy as the first-line diagnostic tool to confirm rectal varices as the bleeding source 1
• Consider urgent colonoscopy within 24 hours if high-risk features or ongoing bleeding are present 1
• Endoscopic ultrasonography is superior to standard endoscopy for diagnosing rectal varices and can assess bleeding risk 2

Immediate Stabilization

For mild bleeding, provide intravenous fluid replacement, blood transfusion if necessary, and correct any coagulopathy 1

For severe bleeding, maintain hemoglobin ≥7 g/dL (4.5 mmol/L) and mean arterial pressure >65 mmHg during resuscitation, while avoiding fluid overload 1

Pharmacological Management

Vasoactive Drugs

• Initiate vasoactive drugs such as terlipressin or octreotide to reduce splanchnic blood flow and portal pressure 1, 3
• These medications should be started early in the treatment course 4

Beta-Blockers

• Use non-selective beta-adrenergic blockers for prevention/prophylaxis of first and recurrent variceal bleeding 1
• Temporarily suspend beta-blockers during acute bleeding episodes 1

Antibiotic Prophylaxis

• Administer a short course of prophylactic antibiotics in all patients with bleeding anorectal varices (strong recommendation) 1
• This reduces infection risk and improves survival 4

Endoscopic Intervention

First-Line Local Procedures

Use local endoscopic procedures to arrest bleeding when feasible, including 1:

• Endoscopic variceal ligation
• Endoscopic band ligation
• Sclerotherapy
• EUS-guided glue injection

Important caveat: Endoscopic injection sclerotherapy has been reported more effective than band ligation for rectal varices specifically, with lower rebleeding rates 2

Bridging Maneuvers

• Consider endorectal placement of a compression tube as a bridging maneuver to stabilize the patient or allow transfer to a tertiary hospital 1

Interventional Radiology (Step-Up Approach)

When Medical and Endoscopic Treatment Fails

Follow a "step up" approach with radiological procedures before considering surgery 1

Embolization

• Use embolization via interventional radiological techniques for short-term control of bleeding 1

TIPS (Transjugular Intrahepatic Portosystemic Shunt)

• Perform percutaneous TIPS in patients with severe portal hypertension (if not contraindicated) to decompress the portal venous system and reduce rebleeding risk 1
• TIPS is recommended for acute variceal bleeding unresponsive to endoscopy and drug therapy 1
• Critical warning: TIPS can cause hepatic encephalopathy in one-third of patients and may precipitate liver failure, particularly in elderly patients with advanced cirrhosis 1, 5

Alternative Interventional Procedures

• Balloon-occluded retrograde transvenous obliteration (BRTO) has been successfully used to treat bleeding rectal varices 2

Surgical Management (Last Resort)

Indications for Surgery

• Reserve surgical procedures for patients with bleeding anorectal varices who have failed medical treatment, local endoscopic procedures, AND radiological interventions 1

Surgical Options

• Avoid "per anal" suture ligation (weak recommendation against this approach) 1
• Surgical porto-caval shunts are considered when all other methods have failed 2
• No recommendation can be made regarding Doppler-guided hemorrhoidal artery ligation or stapled anopexy based on available evidence 1

Multidisciplinary Coordination

Early involvement of hepatology specialist team is essential, focusing on optimal control of comorbid conditions and underlying portal hypertension 1

Common Pitfalls to Avoid

• Do not confuse rectal varices with lower extremity varicose veins or hemorrhoids - they require entirely different management approaches 6, 7, 2
• Do not delay TIPS in appropriate candidates - it is effective for acute variceal bleeding unresponsive to standard therapy, though patient selection is critical given complication risks 1
• Do not forget antibiotic prophylaxis - this is a strong recommendation that improves outcomes 1
• Do not continue beta-blockers during acute bleeding - temporarily suspend them and restart for secondary prophylaxis after bleeding is controlled 1