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.
Cause of Bleeding Varices
Portal hypertension is an increase in the pressure within the portal vein (the vein that carries blood from the digestive organs to the liver). It's often due to scarring of the liver, or cirrhosis.
This increased pressure in the portal vein causes blood to be pushed away from the liver to smaller blood vessels, which are not able to handle the increased amount of blood. This leads to the development of large, swollen veins (varices) within the esophagus, stomach, rectum, and umbilical area (around the belly button). The varices are fragile and can rupture easily, resulting in a large amount of blood loss.
Can Bleeding Varices Be Prevented?
Treating the underlying cause of bleeding varices can help prevent their return. Earlier treatment of liver disease may prevent them from developing.
Certain medications, including the class of heart drugs called "beta-blockers," may reduce elevated portal pressure and lower the likelihood of bleeding. Long-acting nitroglycerines are also used for this purpose.
The term “ectopic varices” (EcV) describes dilated portosystemic collateral veins located in unusual sites other than the gastro-oesophageal (G-O) region including the ectopic isolated gastric varices type 2 (IGV2). This definition has previously been given to any gastrointestinal mucosa-associated abnormally dilated tortuous veins that may lead to gastrointestinal bleeding. In addition, the term has also been given to any portosystemic collateral veins located in the abdominal wall or in the retroperitoneal space.
As no randomized-controlled trials (RCTs) have previously addressed the therapeutic modalities of EcV, most of the available knowledge about this entity is obtained from small case series, case reports and mini-reviews. Awareness of the existence and the therapeutic options of EcV is essential for any physician dealing with patients with gastrointestinal bleeding. This is crucial not only because EcV represent up to 5% of all variceal bleeding episodes but also because of the difficulty in their management and the high mortality secondary to their initial bleeding (up to 40%) .
Nowadays, EcV are diagnosed more frequently because of the recent advances in radiological and endoscopic techniques such as double-balloon enteroscopy (DBE) and video capsule endoscopy (PillCam). Indeed, about 8.1% of patients with portal hypertension (PHT) who underwent capsule endoscopy have small-bowel varices . In this review, we present the currently available knowledge relating to the sites, types, pathogenesis, diagnosis and management of EcV.
Role of capsule endoscopy (PillCam)
About 8.1% of patients with PHT who have undergone capsule endoscopy have small-bowel varices . This number reflects a prevalence that is generally higher than expected and points to the role of capsule endoscopy as a non-invasive tool in the workup of patients with obscure gastrointestinal bleeding, including those with chronic liver diseases. Also, a case report by Fix et al. has shown the significance of PillCam in diagnosing obscure gastrointestinal bleeding from mesenteric varices. It has also been found to be beneficial in detecting small-bowel varices in a patient after Whipple’s operation . Furthermore, PillCam as an alternative to upper endoscopy has been tested in 32 patients with liver cirrhosis for the detection of OG varices and portal hypertensive gastropathy . In one patient, PillCam detected small varices that were not seen at endoscopy, and the overall concordance between both modalities was 96.9 and 90.6% for the diagnosis of varices and gastropathy, respectively, without any adverse effects related to PillCam . A large-scale trial is underway to validate and expand these findings.
Role of DBE
At ileocolonoscopy, 18% of patients with liver cirrhosis and PHT have ileal varices DBE has the potential to visualize the whole small bowel, take biopsy specimens, and perform all necessary endoscopic interventions . Hekmat et al. have recently demonstrated a successful obliteration of a jejunal varix by using N-butyl-2-cyanoacrylate (Histoacryl) in a lesion found ∼240 cm from the ligament of Treitz. This signifies the therapeutic benefit of DBE over capsule endoscopy in small-bowel EcV. The widespread use of this modality in the future would help detect such varices and allow therapeutic intervention, and hence reduce rebleeding, transfusions, and may be mortality.
Similar to acute OG variceal bleeding, clinical assessment, resuscitation, haemodynamic stabilization, antibiotic prophylaxis and referral to specialist centres should be started as soon as possible in patients with suspected EcV bleeding.
The use of vasoactive drugs such as octreotide and terlipressin to reduce splanchnic blood flow and variceal pressure may be of benefit as in patients with bleeding from OG varices . The role of these vasoactive drugs in the control of bleeding from EcV has not been addressed.
All subjects with suspected variceal bleeding should undergo emergency upper endoscopy as a first-line investigation. If it fails to show the source of upper gastrointestinal bleeding, colonoscopy after a rapid colonic purge (3 litres of polyethylene glycol solution delivered via a nasogastric tube) should be the second step of investigation because in a series of 22% of French patients with EcV, bleeding was reported from the colon or rectum Colonic and rectal varices appear as serpiginous, dilated bluish vessels projecting into the lumen. However, if panendoscopy fails to identify and localize a variceal or a non-variceal source of bleeding, capsule endoscopy, DBE, transfemoral angiography or TC-99m red blood cell scintigraphy or other modalities, as mentioned above, would be the third step of the investigation.
Updates in the pathogenesis, diagnosis and management of ectopic varices
Bleeding Varices Symptoms, Causes, and Treatments
Rectal bleeding in a patient with portal hypertension -- 77 (912): 669 -- Postgraduate Medical Journal
Last edited by Medical Photos; 09-15-2015 at 08:25 PM.
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