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Rectal bleeding in a patient with portal hypertension

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Q1: What was the most probable cause of rectal bleeding in this woman?

The cause of rectal bleeding was rupture of rectal varices.

Q2: What is the prevalence of this condition in portal hypertension?

The prevalence of rectal varices in the patients with portal hypertension is quite high and varies from 43%–78%. However bleeding from rectal varices is rare: the incidence is between 1% and 8%.

Q3: What is the management?

There is no definitive guideline for the management of rectal variceal bleed. Conservative management may be all that is needed in mild cases and the bleeding may be self limiting. On the other hand it may be life threatening. Injection sclerotherapy, ligation of varices, transjugular intrahepatic portosystemic shunts (TIPS), and surgical portosystemic shunts have been tried with variable success.

Discussion

Bleeding from gastro-oesophageal varices is a life threatening complication of portal hypertension. Varices may also develop in other parts of the gastrointestinal tract. Large bowel is the second most common site of ectopic varices. The prevalence of this condition ranges between 43% and 78%.1-3 The development of colorectal varices is dependent upon the degree of portal hypertension but does not depend upon its cause.4 Theoretically, obliteration of oesophageal varices either by banding or sclerotherapy may facilitate development of colorectal varices by increase in the blood flow through other portosystemic anastomoses. There is, however, no evidence to suggest that these treatment increase the prevalence of rectal varices.

Bleeding from rectal varices is rare. The incidence varies between 1% and 8%.1 4 5 The severity may vary between mild to life threatening. Flexible sigmoidoscopy and colonoscopy can usually detect the varices but endoscopic ultrasound is more sensitive. Inferior mesenteric arteriography with special attention to the venous phase is very sensitive and is the diagnostic test of choice.

Conservative treatment with fluid replacement, blood transfusion, and correction of coagulopathy may be all that is needed in mild cases. Octreotide has been used to control severe variceal bleeding.

There is no consensus about the interventional management of rectal varices. Endoscopic ligation of the varices and injection sclerotherapy has been tried with variable success.6 Other methods that have been attempted are TIPS and surgical portosystemic shunt. The former can be complicated by stent occlusion and the latter by the development of hepatic encephalopathy. In some cases colectomy is the only option though this itself can be a major undertaking in advanced cirrhotic patients.

Final diagnosis

Bleeding from rectal varices.

References

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