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Rectal bleeding in a patient with portal hypertension

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A 77 year old woman presented for the first time in 1997 with severe haematemesis and melena. After initial resuscitation she underwent an emergency upper gastrointestinal endoscopy which showed bleeding oesophageal varices. She was treated with injection sclerotherapy.

She had a history of ischaemic heart disease but was stable on medication. She was not known to have any other medical problems.

Clinically she was pale but not jaundiced. There was mild ascites and prominent abdominal veins. The splenic tip was just palpable below the left costal margin. Her liver function tests were normal. There was no coagulation abnormality. Ultrasound scan of the abdomen showed normal hepatic architecture. The spleen was enlarged and there was evidence of ascites. Portal blood flow studies suggested portal hypertension secondary to thrombus in the portal vein. After discharge from the hospital she was kept under endoscopic surveillance. The variceal recurrences needed repeated ligation.

Three years later she had to be admitted again, this time for the investigation of bleeding per rectum. It was intermittent, self limiting, and small in amount. Her bowel habits were normal. Clinical examination revealed pallor, mild ascites, and prominent abdominal veins. Her spleen was palpable 2 cm below the costal margin. Figure 1shows the finding on flexible sigmoidoscopy. Her barium enema was normal.

Figure 1

Finding on flexible sigmoidoscopy.


What was the most probable cause of rectal bleeding in this woman?
What is the prevalence of this condition in portal hypertension?
What is the management?

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