Rectal Varices

Dilated submucosal veins of the lower rectum that are portosystemic collaterals between the superior rectal veins (portal drainage) and the middle and inferior rectal veins (systemic drainage), formed in portal hypertension; they are distinct from haemorrhoids, which are vascular cushions of the anal canal.

• Found in about 40 to 90% of patients with portal hypertension on endoscopic examination; clinically important bleeding is uncommon (about 1 to 5% of those with varices) but accounts for about 1 to 8% of bleeding episodes in portal hypertension and can be massive and recurrent.
• Causes: cirrhosis, schistosomiasis, extrahepatic portal vein obstruction (often in children), Budd-Chiari syndrome, and idiopathic non-cirrhotic portal hypertension.
• Mechanism: raised portal pressure reverses flow in the superior rectal vein, which drains through anastomoses into the middle and inferior rectal veins; thin-walled submucosal veins at the dentate line dilate and rupture.

Usually asymptomatic; painless rectal bleeding (bright red blood or maroon stool) that may be recurrent or massive, melaena, iron deficiency anaemia, or occult bleeding.

• Stigmata of portal hypertension: ascites, splenomegaly, caput medusae, jaundice; history of liver disease or schistosomiasis.
• Differential diagnosis: haemorrhoids (can coexist), ulcer from NSAIDs, solitary rectal ulcer, ischaemic or infective colitis, diverticular bleeding, angiodysplasia, colorectal cancer, portal hypertensive colopathy, radiation proctitis, upper gastrointestinal bleeding (varices).
• Complications: severe haemorrhage with shock, recurrent bleeding, iron deficiency anaemia, encephalopathy precipitated by bleeding, and death in decompensated liver disease.

Proctoscopy or colonoscopy shows blue or red, serpiginous or tortuous submucosal veins extending proximally from the anorectal junction for more than 4 cm, usually with a smooth surface, sometimes with red spots; do not biopsy a varix.

• Distinguish from haemorrhoids: varices are tortuous, blue and extend proximal to the dentate line, whereas haemorrhoids are cushion-like lesions in the anal canal.
• CT or MR angiography, or endoscopic ultrasound with Doppler: confirms the varices, their feeder and draining veins, and the cause of portal hypertension.
• Blood tests: full blood count, ferritin, INR, albumin, bilirubin, creatinine, group and crossmatch; hepatitis serology.
• Upper endoscopy to look for oesophageal and gastric varices and portal hypertensive gastropathy as other bleeding sources; Doppler ultrasound for portal vein patency.

Resuscitate, control bleeding locally, reduce portal pressure, and avoid haemorrhoid surgery.

• Resuscitation: two large-bore cannulae, careful volume replacement, restrictive transfusion at haemoglobin 70 g/L (target 70 to 80 g/L), correction of severe coagulopathy, and monitoring in a high-dependency unit.
• Vasoactive drugs for 2 to 5 days: terlipressin 2 mg IV every 4 hours for 48 hours then 1 mg every 4 hours, or octreotide 50 micrograms IV bolus then 50 micrograms/hour; ceftriaxone 1 g IV daily for up to 7 days; lactulose 30 mL every 8 hours if there is encephalopathy risk.
• Local haemostasis at proctoscopy or colonoscopy:
  • Digital pressure or packing as a bridge.
  • Under-running (suture ligation) of the bleeding varix with an absorbable suture (3-0 polyglactin) through the mucosa, reliable for acute bleeding.
  • Band ligation (single or multiple) of the varix, or sclerotherapy (ethanolamine oleate 5% 1 to 2 mL per injection, polidocanol 1% to 3%, or cyanoacrylate glue 0.5 to 1 mL).
  • Avoid haemorrhoidectomy and rubber band ligation of haemorrhoids in portal hypertension.
• Reduce portal pressure: carvedilol 6.25 mg once daily increasing to 6.25 mg twice daily, or propranolol 20 to 40 mg twice daily (heart rate 55 to 60 beats/min; maximum 160 mg daily without ascites), for secondary prophylaxis.
• Recurrent or refractory bleeding: transjugular intrahepatic portosystemic shunt with or without embolisation of the varices (effective in more than 80%), or direct embolisation by interventional radiology; liver transplantation when liver disease is advanced.
• Treat the cause: alcohol abstinence, hepatitis B (tenofovir 245 mg daily or entecavir 0.5 mg daily), hepatitis C (sofosbuvir-velpatasvir 400/100 mg daily for 12 weeks), schistosomiasis (praziquantel 40 mg/kg once), portal vein thrombosis (anticoagulation), Budd-Chiari syndrome (anticoagulation and shunt).
• Iron replacement: ferrous sulfate 200 mg once daily or on alternate days, or ferric carboxymaltose 1000 mg IV once, to correct anaemia.
• Special groups: children (extrahepatic portal vein obstruction: propranolol 1 mg/kg/day, local sclerotherapy, shunt surgery such as mesenterico-left portal bypass); pregnancy (local therapy and octreotide, avoid terlipressin, multidisciplinary delivery planning); elderly (cautious beta blocker use); renal impairment (avoid NSAIDs and aminoglycosides); anticoagulated patients (balance bleeding risk with indication).
• Red flags: massive rectal bleeding, shock, melaena with haematemesis, encephalopathy, fever, jaundice, rising creatinine, rebleeding after local therapy.
• Follow-up: repeat proctoscopy at 2 to 4 weeks after treatment; haemoglobin and ferritin at 4 to 8 weeks; liver tests and portal hypertension management every 3 months; endoscopy for oesophageal and gastric varices as scheduled.