1. Joint Hospital Surgical Grand Round Unusual cause of LGIB
Jason LI

2. Case presentation M/55 Known child B cirrhosis, HBV related
History of esophageal varices with EBL in 2014
Last surveillance OGD 1 month ago: minimal varices with no banding required
Developed hematochezia (fresh blood + clots)
Hemodynamically stable

3. Proctoscopy: Few areas of active oozing around 5cm from anal verge
Proctoscopy: Few areas of active oozing around 5cm from anal verge. Lots of blood with underlying pathology cannot be seen
On call team impression: bleeding mucosal lesions (ulcers/haemorrhoids)

4. Tried to plicate with 2/0 vicryl
Tried to plicate with 2/0 vicryl. Failed and resulted in more severe bleeding >200ml
Patient developed tachycardia. Cold and clammy periphery. BP marginal
Packed with adrenaline gauze and rushed into endoscopy room

5. Emergency flexible sigmoidoscopy

6. Introduction
Varices
Commonest: Esophagogastric
Others: small + large bowels, retroperitoneal
Treatment for esophageal varices is well established
Endoscopic band ligation (EBL)
Endoscopic injection sclerotherapy (EIS)
Garcia-Tsao G, Hepatology 2007

7. Rectal varices First reported case in 1954 Definition
Dilated veins that originate > 4cm above anal verge
Not contiguous with anal columns or dentate line
Cabot RC, N Engl J Med 1954
Ganguly S, Hepatology 1995

8. Epidemiology Prevalence Clinically significant bleeding: 0.5-5%
Cirrhotic patient: 38-56%
Extrahepatic portal vein obstruction 63-94%
Clinically significant bleeding: 0.5-5%
Misra SP, Endoscopy 2005
Shudo R, Endoscopy 2002

9. Pathogenesis Portal hypertension
Varices occurs at least 12mmHg in portal pressure gradient
Collaterals between portal and systemic circulations
Manifest as dilation of submucosal veins
This is the schematic diagram showing how portal blood shunt to systemic circulation in rectal plexus.
The superior rectal vein divides into two branches, which enter the lateral wall of rectum, about 10 cm from dentate line. The middle and inferior rectal veins, empty into the caval system. The rectal veins form two plexuses, an internal one lying in the submucosa and an external one lying outside the muscular wall of the bowel. The intrinsic rectal venous plexus consists of two groups of veins. The inferior group passes down to form the inferior rectal veins, and dilation of this group leads to formation of external hemorrhoids. The vessels of the superior group in the anal columns lead to the formation of internal hemorrhoids and in the rectum lead to the formation of rectal varices.
Malay S, Gastroenterol Res Pract 2013

10. Pathogenesis Correlated with severity of cirrhosis
Correlated with esophageal varices
Cirrhosis + NO esophageal varices: 19%
Cirrhosis + esophageal varices: 39%
Cirrhosis + bleeding esophageal varices: 59%
Moller S, Gut 2011
Hosking SW, Lancet 1989

11. Pathogenesis Related to obliteration of esophageal varices
95%: history of esophgeal varices
87% of these patient had EBL or EIS
Postulation: obliteration of shunts to superior mesenteric vein => development of shunt in inferior mesenteric vein
Watanabe N, Hepatol Res 2010

12. Diagnosis
Clinical: hematochezia
Lower endoscopy

13. Endoscopic ultrasound
Echo-free structures in submucosa
Perirectal collateral veins outside rectal wall
Deep rectal varices not seen in endoscopy
Better detection than endoscopy (85% vs 45%)
Predicts risk of bleeding
Identify proper site of intervention
Dhiman RK, Gastrointest Endosc 1993
Sato T, Hepato Res 2003

14. Treatment Resuscitation +/- blood transfusion
SBP mmHg
Pulse < 100 bpm
Hb ~8g/dL
Correction of coagulopathy
Prophylactic antibiotics: prevent hepatic encephalopathy + spontaneous bacterial peritonitis
Role of vasoactive drugs?
Asian pacific association for study of liver

15. Endoscopic treatment Endoscopic injection sclerotherapy
First reported useful in 1985
5% ethanolamine oleate
Under fluoroscopic guidance
Evaluate hemodyanmic before injection
Recurrence rate: 24% during 1 year FU
Sato T, Clin Exp Gastroenterol 2010

16. Endoscopic treatment Endoscopic band ligation
Well established in esophageal varices
Demonstrates less complication than EIS
Several case reports: supportive
Compared with EIS
Recurrence rate is more (33.3% vs 55.6%)
No complication in EIS
One complication in EBL: bleeding rectal ulcer
Sato T, Clin Exp Gastroenterol 2010

17. Interventional radiology
Transjugular intrahepatic portosystemic shunt (TIPS)
Bridge for transplant
Avoid surgical shunting
First used for rectal varices in 1993
Largest series in 2008
67% successful rate
Problem: larger vein in rectal varices => lower portal pressure needed?
N = 28
Kochar N, Aliment Pharmacol Ther 2008

18. Interventional radiology
Embolisation (antegrade)
Usually performed with TIPS
Transhepatic approach: cannulation of right anterior branch of intrahepatic portal vein
Angiogram demonstrates shunting
Injection of occlusive materials in afferent veins
Coils, gelfoam, thrombin, collagen, autologous blood clots
CT: accumulation of lipiodol in rectal varices
Ahn SS, World J Gastroenterol 2015

19. Interventional radiology
Balloon occluded retrograde transvenous obliteration
Occlude outflow of portosystemic shunt
Compared with TIPS
Less invasive
Better in patient with poor liver reserve + HE
Potential increase in portal pressure?
One case report: worsening of pre-existing OV
Yoshino K, Hepatol Res 2014

20. Surgical treatment Simple suture ligation
Technically challenging + often not successful
Inferior mesenteric vein occlusion
Porto-caval shunt
80% mortality rate within 2 months
Bittinger M, Gastrointest Endosc 2004

21. Surgical treatment Stapled device First reported in 2002
Successfully control bleeding after failure of EIS/EBL
No further rebleeding in 2 years
All are case report/series
Kaul AK, Colorectal Dis 2009

22. Conclusion
Important differential diagnosis for PR bleeding in cirrhotic patient
Treatment is more or less like esophageal varices (though evidence is not well established)
No head-to-head comparison between different treatment modalities
Prophylactic treatment?