Massive Bleeding From Hemorrhoidal Varices in Portal Hypertension

GASTROINTESTINAL bleeding in patients with portal hypertension frequently results from ruptured esophagogastric varices. Although an alternative site of natural decompression of the portal system occurs via communications from the superior hemorrhoidal to the middle and inferior hemorrhoidal veins through the submucosa of the distal rectum, severe bleeding from such hemorrhoidal varices has rarely been reported. The management of such bleeding is a matter of conjecture, and recommendations range from watchful waiting to the performance of a portasystemic shunt.1,2Our recent experience with a cirrhotic patient who bled massively from hemorrhoidal varices is illustrative of the problem and suggests a rational approach to therapy. Report of a Case A 55-year-old man with known alcoholic cirrhosis, portal hypertension, ascites, and esophageal varices was admitted to the Medicine Service of the Veterans Administration Hospital, San Diego, because of rectal bleeding. For several months before this hospital admission, he had had numerous episodes