Portal Hypertensive Rectopathy

Portal hypertensive rectopathy is a spectrum of rectal mucosal changes (erythema, friability, vascular ectasia, mucosal ulceration and rectal varices) caused by portal hypertension.

Rectal varices are found in 44% to 89% of cirrhotic patients undergoing endoscopy; rectopathy features are found in up to half. Bleeding from rectal varices causes 1% to 8% of bleeding in portal hypertension but can be severe.

Risk factors are higher portal pressure, oesophageal and gastric varices, Child-Pugh class B or C, previous variceal therapy and extrahepatic portal obstruction.

Pathophysiology.

Portosystemic collaterals form between the superior rectal vein (portal) and the middle and inferior rectal veins (systemic). Rectal mucosal vessels become congested and dilated, with reduced mucosal defence.

Often none. Painless rectal bleeding, melaena, haematochezia with anaemia, and rarely massive haemorrhage with shock.

Red flags.

• Haemodynamic instability.
• Massive rectal bleeding.
• Hepatic decompensation.

Proctoscopy and colonoscopy show bluish serpiginous submucosal varices that bleed on touch, or diffuse erythema, red spots and friable mucosa. Endoscopic ultrasound or CT angiography shows collaterals. Assess liver function, platelets and INR. Look for other bleeding sources.

Differential diagnosis.

• Haemorrhoids.
• Solitary rectal ulcer.
• Radiation proctitis.
• Ischaemic proctitis.
• Inflammatory bowel disease.
• Rectal cancer.

Haemorrhoids and rectal varices must be distinguished, since haemorrhoidectomy in portal hypertension can cause fatal bleeding.

• Terlipressin: 2 mg IV every 4 hours for the first 24 to 48 hours, then 1 mg every 4 hours; up to 5 days; maximum 12 mg daily initially; monitor ischaemia, sodium, ECG and fluid overload; avoid in ischaemic heart disease, peripheral vascular disease and severe asthma.
• Ceftriaxone: 1 g IV once daily; up to 7 days; maximum 2 g daily; monitor renal function and rash; no adjustment in mild impairment.

Restrict transfusion to a haemoglobin threshold of 70 g/L (target 70 to 90 g/L). Control bleeding by suturing or band ligation, cyanoacrylate injection or sclerotherapy of varices. Interventional options are transjugular intrahepatic portosystemic shunt and coil embolisation; surgical devascularisation is rarely needed.

Long term:

• Carvedilol: 6.25 mg orally once daily for 3 days, then 12.5 mg once daily; indefinitely; maximum 12.5 mg daily (25 mg without ascites in some practice); monitor blood pressure (systolic 90 mmHg or more) and heart rate; reduce or stop in refractory ascites with low blood pressure, renal failure or sepsis.
• Propranolol (alternative): 20 to 40 mg orally twice daily, titrated to a resting heart rate of 55 to 60/min; maximum 160 mg daily (80 mg with ascites); monitor heart rate, blood pressure and glucose; avoid in asthma and heart block.

Treat the cause of the liver disease and assess for liver transplantation.

Monitoring. Haemoglobin, heart rate and blood pressure; repeat endoscopy at 4 to 8 weeks.

Referral and escalation. Hepatology, interventional radiology and colorectal surgery.