Treatment of Bleeding Rectal Varices With Transumbilical Venous Obliteration of the Inferior Mesenteric Vein

Abstract

A 56-year-old male with alcohol-induced liver cirrhosis developed rectal varices. He had a prior history of treatment for esophageal varices with endoscopic variceal ligation. Despite the repeated treatment for rectal varices with endoscopic variceal ligation, endoscopic injection sclerotherapy, and surgery, the bleeding from the rectal varices could not be controlled. Multidetector-row computed tomography and 3D-angiography revealed the hemodynamic profile of the rectal varices. We next approached the rectal varices through the umbilical vein on the abdominal wall, and successfully embolized the varices continuing from the inferior mesenteric vein using coils and a 5% solution of ethanolamine oleate with iopamidol.

Management options for rectal variceal bleeding in the setting of hepatic encephalopathy

“…With regards to patients with hepatic encephalopathy, angioembolization is a reasonable alternative to the mentioned radiological strategies for managing rectal variceal bleeding and thus proved useful in our patient to control acute, severe rectal variceal bleeding. Angioembolization can be completed via a transhepatic approach (as with the reported case) to localize the bleeding target; however, other approaches have been described 25,31,32 . Angioembolization is minimally invasive, can be both a diagnostic and therapeutic procedure and achieves haemostasis by occluding the vein that contributes to the bleeding varix.…”

“…Angioembolization can be completed via a transhepatic approach (as with the reported case) to localize the bleeding target; however, other approaches have been described. 25,31,32 Angioembolization is minimally invasive, can be both a diagnostic and therapeutic procedure and achieves haemostasis by occluding the vein that contributes to the bleeding varix. Various embolization materials are utilized, including coils, foam, glue and thrombin.…”

Expert consensus on emergency procedures for portal hypertension bleeding (2022)

“…Inferior mesenteric vein ligation: In patients with refractory anal canal and rectal variceal bleeding, mesenteric vein ligation is a feasible surgical approach. 60 …”

Management of Gastric and Ectopic Varices: The Endoscopist's Perspective

“…Alternative endovascular therapies such as BRTO have also been reported for the management of RVs, but there are less data to support their use as compared with TIPS and band ligation. [98][99][100] Therefore, initial therapy for RVs should include endoscopic therapy with follow-up examination every 2 to 4 weeks to assess for the eradication of varices. For recurrent bleeding or early rebleeding, TIPS with direct embolization/sclerosis of the RVs should be completed.…”