Rectal varices are reported in about 38% to 94% of patients with portal hypertension1Misra S.P. Dwivedi M. Misra V. Prevalence and factors influencing hemorrhoids, anorectal varices, and colopathy in patients with portal hypertension.Endoscopy. 1996; 28: 340-345Crossref PubMed Scopus (87) Google Scholar; however, they present with significant bleeding in fewer than 5% of patients.2Coelho-Prabhu N. Baron T.H. Kamath P.S. Endoscopic band ligation of rectal varices: a case series.Endoscopy. 2010; 42: 173-176Crossref PubMed Scopus (13) Google Scholar The current treatment options for bleeding rectal varices include endoscopic injection sclerotherapy (EIS), endoscopic band ligation,2Coelho-Prabhu N. Baron T.H. Kamath P.S. Endoscopic band ligation of rectal varices: a case series.Endoscopy. 2010; 42: 173-176Crossref PubMed Scopus (13) Google Scholar transjugular intrahepatic portosystemic shunt placement, balloon-occluded retrograde transvenous obliteration,3Al Khalloufi K. Laiyemo A.O. Management of rectal varices in portal hypertension.World J Hepatol. 2015; 7: 2992-2998Crossref PubMed Scopus (28) Google Scholar and cyanoacrylate alone4Romero-Castro R. Ellrichmann M. Ortiz-Moyano C. et al.EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos).Gastrointest Endosc. 2013; 78: 711-721Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar or a combination of cyanoacrylate and coils.5Weilert F. Shah J.N. Marson F.P. et al.EUS-guided coil and glue for bleeding rectal varix.Gastrointest Endosc. 2012; 76: 915-916Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar We report a case of rectal variceal bleeding managed with EUS-guided coiling alone. A 65-year-old man with alcohol-related decompensated cirrhosis of the liver with portal hypertension (Model for End-Stage Liver Disease [MELD] score of 25) presented with recurrent lower GI bleeding to a local hospital, where he underwent multiple sessions of sclerotherapy for hemorrhoids. He had received multiple transfusions of packed red blood cells and fresh frozen plasma at the local hospital, but inasmuch as his bleeding persisted, he was referred to our center. At our center, after initial hemodynamic stabilization, sigmoidoscopy revealed large rectal varices (Fig. 1), not hemorrhoids, as previously thought, with active bleeding from 2 sites (Fig. 2). Rectal varices were distinguished from hemorrhoids. Rectal varices were more than 4 cm above the dentate line.6Ganguly S. Sarin S.K. Bhatia V. et al.The prevalence and spectrum of colonic lesions in patients with cirrhotic and noncirrhotic portal hypertension.Hepatology. 1995; 21: 1226-1231PubMed Google Scholar EIS was done with 16 mL sodium tetradecyl sulfate 1% into 4 sites, but we were unable to achieve hemostasis. Because of persistent active bleeding, 2 mL of cyanoacrylate was injected under direct vision onto the bleeding site (Video 1, available online at www.VideoGIE.org). Hemostasis was achieved, and the patient was discharged.Figure 2Colonoscopic view showing active bleeding from rectal varix.View Large Image Figure ViewerDownload Hi-res image Download (PPT) A week later he presented again with lower GI bleeding. A repeat sigmoidoscopy showed a thrombosed area of previous glue injection. No soft areas could be identified on probing with closed biopsy forceps. As our experience with coils for the management of gastric varices and duodenal varix was good,7Mukkada R.J. Chooracken M. Antony R. et al.EUS-guided coiling for bleeding duodenal collateral vessel.Gastrointest Endosc. 2016; 84 ([abstract]): 1057-1058Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar we opted to do an EUS to assess the feasibility of EUS-guided coiling. EUS showed large, submucosal, rectal collateral varices (Fig. 3). The Doppler study showed good flow velocity (Fig. 4). EUS-guided coiling was done using a 19G needle as previously reported.5Weilert F. Shah J.N. Marson F.P. et al.EUS-guided coil and glue for bleeding rectal varix.Gastrointest Endosc. 2012; 76: 915-916Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar The varix was punctured with a single sharp jab, the stylet was withdrawn, and two 5-mm coils were deployed under EUS guidance. Selection of the coils was based on the diameter of the varix, which was 5.9 mm. Because larger coils of the same size or bigger were unavailable, we chose to place two 5-mm coils. A repeat Doppler study done immediately after coil deployment showed significant reduction of flow. The absence of Doppler flow was reconfirmed after 2 minutes, and the needle was removed (Fig. 5).Figure 4Pre-embolization pulse wave spectral Doppler tracing of rectal varices showing good flow.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Post-embolization pulse wave spectral Doppler showing absence of flow.View Large Image Figure ViewerDownload Hi-res image Download (PPT) During EUS, rectal varices are seen to be rounded, oval, or longitudinal hypoechoic areas in the submucosa. Perirectal collateral veins may also be seen outside the rectal wall.8Wiechowska-Kozłowska A. Białek A. Milkiewicz P. Prevalence of “deep”rectal varices in patients with cirrhosis: an EUS-based study.Liver Int. 2009; 29: 1202-1205Crossref PubMed Scopus (17) Google Scholar Sharma and Somasundaram9Sharma M. Somasundaram A. Massive lower GI bleed from an endoscopically inevident rectal varices: diagnosis and management by EUS (with videos).Gastrointest Endosc. 2010; 72: 1106-1108Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar described EUS-guided glue injection as a viable option in bleeding rectal varices. Romero-Castro et al10Romero-Castro R. Pellicer-Bautista F. Giovannini M. et al.Endoscopic ultrasound (EUS)-guided coil embolization therapy in gastric varices.Endoscopy. 2010; 42: 2009-2010Crossref Scopus (74) Google Scholar described their case series of EUS-guided coiling for rectal varices for which they had used multiple coils. Weilert et al5Weilert F. Shah J.N. Marson F.P. et al.EUS-guided coil and glue for bleeding rectal varix.Gastrointest Endosc. 2012; 76: 915-916Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar described the use of coils and glue in their series and used multiple glue injections and coils in their study; however, in the present case there was no further requirement for injection of glue or for coil because Doppler flow had disappeared completely with the initial deployment of 2 coils. Messallam et al11Messallam A.A. Kumbhari V. Saxena P. et al.Large bleeding rectal varices treated with endoscopic ultrasound-guided coiling and cyanoacrylate injection.Endoscopy. 2014; 46: E28-E29Crossref PubMed Scopus (3) Google Scholar reported the use of coils along with glue for bleeding rectal varices, but they completed the procedure in 2 sessions and required more glue. Our patient was followed up for 3 months, and he died as a result of adverse events related to decompensated cirrhosis, not because of the bleeding. In patients with cirrhosis and portal hypertension with severe lower GI bleeding, the possibility of rectal varices should be considered. EUS-guided coiling of a rectal varix is an option to control bleeding. All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI2M2JmYmZhZGQ3MTA3NTZlNjIwYWJmNDFmZDg5MWIxZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4ODEzNjE1fQ.G_CUolvEv-zjgXL4EwNWYjsvoJFveA_Q4Cj1n42SV9JVaMrI74wqvMnjAI6hqV73t-GdlhpOIJJtgezG8ye_C31-5OjcjDQzPfRAK59sH-BWBtEVWgC9dkh18CG_WOv39Mbtf39Z9GyvEnsl_JcO8oarokuOYNxeMQBIqQrTOIYe5h-IU5_LqQmTMJhHajwexOqC9wQYbZMGx63yanNtcCA1Fl4a6M6Sf4UBv1t7pPJuGGDslM1POzwg01J_461TciJ1zj1tWopUowHw95FZxyWTpr10876e4GmoXQ4w2lkrXuBZDEbTLXRyWrGF22q7bAcGpJt9-wHtv5U84A2nKg Download .mp4 (70.46 MB) Help with .mp4 files Video 1Video showing EUS-guided coiling. Download .docx (.02 MB) Help with docx files Video Script
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