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ISSN: 2161-069Xt

e DOI: 10.4172/2161-069X.S6-005 u m o

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Review Article Open Access Treatments for Rectal Varices with Portal Hypertension Takahiro Sato* Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan

Abstract Rectal varices are considered to occur infrequent, however, potentially serious cause of hematochezia. Various treatments have been performed to control bleeding rectal varices. Some investigators have reported that endoscopic treatments such as endoscopic injection sclerotherapy (EIS) and endoscopic band ligation (EBL) were successfully employed for rectal variceal bleeding. EIS may be superior to EBL with regard to long-term effectiveness and complications as endoscopic treatments of rectal varices, and percutaneous transhepatic obliteration may be useful for large rectal varices. Hemorrhage from rectal varices should be kept in mind in patients with portal hypertension presenting with lower gastrointestinal bleeding, however, it is difficult to determine the best medical treatment strategy for rectal varices because of difficulty in diagnosis and subsequent difficulty in treatment.

Keywords: Varices; Hematochezia; Portal hypertension; Sclerotherapy Introduction Esophagogastric varices are considered to be the most common complication in patients with portal hypertension. Ectopic varices that are outside the esophagogastric region are less common, and located predominantly in the duodenum, jejunum, ileum, colon, and . Rectal varices are a potentially serious cause of hematochezia, and several reports that they occur with high frequency in patients with hepatic abnormalities [1-3]. Massive bleeding from rectal varices occurs rarely, and several articles report with a frequency ranging from 0.5% to 3.6% [4-6]. Endoscopic injection sclerotherapy (EIS) and endoscopic band ligation (EBL) for esophageal varices are established therapies; however, there is no best treatment strategy for rectal varices. In this article, we also review the therapies for rectal varices in patients with Figure 1a: Endoscopic findings show tumorous type rectal varices. portal hypertension. Rectal Varices some investigators reported the easily recurrence of rectal varices after EBL [14,15]. Sato et al. performed EIS using 5% ethanolamine oleate Hemodynamic mechanism of rectal varices have been represented with iopamidol (5%EOI), under fluoroscopy without complications, as discrete dilated submucosal of portal venous collateral flow and they retrospectively evaluated the rates of recurrence of rectal between the superior rectal veins of the inferior mesenteric system varices after EIS or EBL [15]. The rates of recurrence of rectal varices and the middle inferior rectal veins of the iliac system, and they have tended to be more frequent with EBL than EIS and they mentioned been reported to occur with a high frequency in those with portal that it is important to evaluate the hemodynamics of the rectal varices hypertension [1-3]. It has been reported that rectal variceal bleeding before EIS procedure to avoid severe complications such as vascular show an increase after EIS for esophageal varices [6], however, Hosking embolism, and 5%EOI of the sclerosant should be slowly injected under et al. revealed no direct association between EIS for esophageal varices fluoroscopy, taking care to ensure that the agent does not flow into and an increased prevalence of rectal varices [1]. the systemic circulation during EIS. We show a case of rectal variceal patient, and present endoscopic findings before EIS (Figure 1a) and the Treatments of Rectal Varices fluoroscopy during EIS (Figure 1b). Shudo et al. successfully performed Various medical treatments such as endoscopic treatments and concurrent EBL and EIS treatment for a case of rectal varices [16]. interventional radiology have been used to control bleeding from rectal Percutaneous transhepatic obliteration (PTO) may be useful for varices, however, there is no best treatment strategy for rectal varices. large rectal varices. Sato et al. show a cirrhotic case with anal bleeding Surgical treatments, including portosystemic shunting, ligation, and of large tortuous rectal varices [17]. Percutaneous transhepatic under-running suturing have been performed [1]. In patients with poor portography was performed by catheterization of the right anterior condition, interventional radiologic techniques such as transjugular intrahepatic portosystemic shunts were successfully employed for rectal variceal bleeding as a non-operative treatment option [7-9]. Wang et al. *Corresponding author: Takahiro Sato, Department of Gastroenterology, found the usefulness of EIS in treating rectal variceal bleeding [10]. On Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, the other hand, Levine et al. treated rectal varices initially with EIS, Japan, E-mail: [email protected] and 1 week later, EBL was performed on the remaining rectal varices Received March 23, 2013; Accepted April 02, 2013; Published April 04, 2013 as additional treatment [11]. EBL was introduced as a new method for treating esophageal varices, and it is reportedly both easier to perform Citation: Sato T (2013) Treatments for Rectal Varices with Portal Hypertension. J Gastroint Dig Syst S6: 005. doi:10.4172/2161-069X.S6-005 and safer than EIS. Some reports revealed the usefulness of EBL in several cases as a treatment of rectal varices [12,13], and described Copyright: © 2013 Sato T. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted EBL as a safe and effective therapy for rectal varices [13]. EBL may be use, distribution, and reproduction in any medium, provided the original author and effective as an initial treatment for rectal variceal bleeding, however, source are credited.

J Gastroint Dig Syst Clinical Diagnosis and Therapy of Colorectal Cancer: State of the Art ISSN: 2161-069X JGDS, an open access journal Citation: Sato T (2013) Treatments for Rectal Varices with Portal Hypertension. J Gastroint Dig Syst S6: 005. doi:10.4172/2161-069X.S6-005

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7. Katz JA, Rubin RA, Cope C, Holland G, Brass CA (1993) Recurrent bleeding Figure 1b: Fluoroscopy during endoscopic injection sclerotherapy. from anorectal varices: successful treatment with a transjugular intrahepatic portosystemic shunt. Am J Gastroenterol 88: 1104-1107. branch of the intrahepatic portal . Hepatofugal blood flow was 8. Shibata D, Brophy DP, Gordon FD, Anastopoulos HT, Sentovich SM, et al. (1999) Transjugular intrahepatic portosystemic shunt for treatment of bleeding observed in the superior rectal vein connected to the inferior mesenteric ectopic varices with portal hypertension. Dis Colon Rectum 42: 1581-1585. vein and the contrast medium passed into the rectal varices. Next, PTO was performed with injection of 5% ethanolamine oleate containing 9. Fantin AC, Zala G, Risti B, Debatin JF, Schöpke W, et al. (1996) Bleeding anorectal varices: successful treatment with transjugular intrahepatic iopamidol and Histoacryl diluted with Lipiodol via the afferent veins portosystemic shunting (TIPS). Gut 38: 932-935. of rectal varices in this case, and computed tomography revealed the successfully therapeutic effect in showing the accumulation of Lipiodol 10. Wang M, Desigan G, Dunn D (1985) Endoscopic sclerotherapy for bleeding rectal varices: a case report. Am J Gastroenterol 80: 779-780. in rectal varices after PTO. A standard best treatment strategy for rectal varices has not been established. It is necessary to evaluate the 11. Levine J, Tahiri A, Banerjee B (1993) Endoscopic ligation of bleeding rectal suitable evidence-based treatment for rectal varices in larger numbers varices. Gastrointest Endosc 39: 188-190. of patients with more investigations. 12. Firoozi B, Gamagaris Z, Weinshel EH, Bini EJ (2002) Endoscopic band ligation of bleeding rectal varices. Dig Dis Sci 47: 1502-1505.

Conclusion 13. Sato T, Yamazaki K, Toyota J, Karino Y, Ohmura T, et al (1999) Two Cases of 1. Hemorrhage from rectal varices should be kept in mind Rectal Varices Treated by Endoscopic Variceal Ligation. Dig. Endosc 11: 66-69. in patients with portal hypertension presenting with lower 14. Shudo R, Yazaki Y, Sakurai S, Uenishi H, Yamada H, et al (2000) Endoscopic gastrointestinal bleeding. Variceal Ligation of Bleeding Rectal Varices: A Case Report. Dig. Endosc 12: 366-368. 2. Endoscopic procedures such as EIS and EBL are useful for rectal 15. Sato T, Yamazaki K, Toyota J, Karino Y, Ohmura T, et al. (2006) The value varices. PTO may be useful for large rectal varices. However, a of the endoscopic therapies in the treatment of rectal varices: a retrospective best medical treatment strategy for rectal varices has not been comparison between injection sclerotherapy and band ligation. Hepatol Res established. It is necessary to evaluate the suitable evidence- 34: 250-255. based treatment for rectal varices in larger numbers of patients 16. Shudo R, Yazaki Y, Sakurai S, Uenishi H, Yamada H, et al (2001) Combined with more investigations. endoscopic variceal ligation and sclerotherapy for bleeding rectal varices associated with primary biliary cirrhosis: a case showing a long-lasting References favorable response. Gastrointestinal Endosc 53:661-665. 1. Hosking SW, Smart HL, Johnson AG, Triger DR (1989) Anorectal varices, 17. Sato T, Yamazaki K, Akaike J (2009) Clinical features of ectopic varices. JJPH haemorrhoids, and portal hypertension. Lancet 1: 349-352. 15:149-53.

This article was originally published in a special issue, Clinical Diagnosis and Therapy of Colorectal Cancer: State of the Art handled by Editor. Dr. Ralph Schneider, Philipps University Marburg, Germany

J Gastroint Dig Syst Clinical Diagnosis and Therapy of Colorectal Cancer: State of the Art ISSN: 2161-069X JGDS, an open access journal