A case of liver cirrhosis due to hepatits C virus infection complicating giant anorectal varices treated with balloon-occluded retrograde transvenous obliteration

Abstract

A 73-year-old man with liver cirrhosis due to hepatitis C virus infection was admitted to our hospital because of massive bleeding from external varices. Colonoscopic examination revealed that giant anorectal varices had developed between the anus and rectal ampulla, and had ruptured at the perianal site. On three-dimensional computed tomography imaging, the feeding and drainage vessels of the varices were identified as the inferior mesenteric vein and right inferior hemorrhoidal vein, respectively. Endoscopic therapies were not employed for the bleeding varices, because the blood flow volume of the feeding vessel was extremely large. Balloon-occluded retrograde transvenous obliteration (B-RTO) was therefore carried out through the drainage vessels. The variceal blood flow disappeared after B-RTO therapy, and the varices decreased in size with thrombus formation verified by colonoscopy. Bleeding from the external varices also ceased. B-RTO therapy may be an effective approach for giant anorectal varices presenting as a complication in liver cirrhosis patients in whom the main drainage vessels can be determined.

A case of liver cirrhosis with bleeding from stomal varices successfully treated using balloon-occluded retrograde transvenous obliteration

“…We reported, however, that the indications for the B-RTO procedure could be expanded when a microballoon catheter was used, making the procedure applicable for gastric fundal varices without a gastrorenal shunt [17] and for ectopic varices such as duodenal varices [18] and rectal varices [7]. The hemodynamic states of these varices are generally complicated, and the structure of each vessel is too tortuous for the advancement of a standard balloon catheter.…”

“…Thus, the varices can be occluded with ethanolamine oleate (EO) infused through a balloon catheter located in the shunt following the occlusion of blood flow by balloon inflation. The B-RTO procedure is also applicable for the treatment of ectopic varices, such as duodenal and rectal varices [6,7]. Most patients with duodenal varices can be treated successfully by the B-RTO procedures.…”

Successful Treatment of Bleeding Rectal Varices with Balloon-Occluded Retrograde Transvenous Obliteration in a Patient with a History of Sigmoidectomy

“…As portal pressure increases, the superior rectal vein changes from an outflow vessel to an inflow vessel, and drains through the middle and inferior rectal veins into numerous internal iliac branch veins. Although some previous reports have described the use of BRTO to treat rectal varices [2,10], it is not usually indicated for rectal varices because rectal varices usually have multiple drainage veins, and numerous collaterals between the iliac venous branches are often difficult to completely occlude with a balloon catheter. In the present case, the superior rectal vein might have been ligated during the previous sigmoidectomy procedure, and the hemodynamics of the pelvic venous plexus might also have changed.…”

“…Various treatments, such as surgical or endoscopic ligation, endoscopic injection sclerotherapy (EIS), percutaneous transhepatic obliteration (PTO) with modified techniques, transjugular intrahepatic portosystemic shunt (TIPS), and balloon-occluded retrograde transvenous obliteration (BRTO), have been used to control bleeding from rectal varices; however, there is no standard treatment for the condition [2][3][4][5][6][7][8][9][10]. In general, rectal varices have numerous drainage vessels that pass through the pelvic venous plexus; therefore, BRTO is usually not feasible for rectal varices, owing to their complex hemodynamics.…”

Transileocolic Vein Obliteration for Bleeding Rectal Varices with Portal Thrombus

“…Currently, various therapies, including endoscopic procedures [5, 6, 7], surgery [8] and direct therapeutic intervention [9, 10, 11, 12], are available for the treatment of rectal varices. Interventional therapy for rectal varices is classified as transjugular intrahepatic portosys temic shunt [9] and transcatheter embolotherapy [10, 11, 12].…”