Rectal variceal bleeding, can at times be difficult to manage through conventional methods and prove fatal if not emergently salvaged. There have been several reports of bleeding rectal varices treated with endoscopic variceal ligation, endoscopic sclerotherapy, transjugular intrahepatic portosystemic shunt and surgery. Even though various strategies have been described in literature, consensus guidelines for management of bleeding rectal varices are lacking due to heterogeneity of associated portosystemic collateral anatomy, due to which, no single effective method has yet been established. In 1997, Kimura et al reported the successful treatment of bleeding rectal varices with a new interventional radiological procedure utilizing double balloon-occlusion assisted embolotherapy. Thereafter reports on modification of this technique for bleeding rectal varices, mostly through balloon-occluded retrograde route and use of sclerosant has been described. Here we report the case of a difficult to manage rectal variceal bleeding, utilizing balloon occluded antegrade technique and cyanoacrylate glue therapy followed by coil embolization for immediate hemostasis achievement translating to beneficial outcome in a Child C cirrhotic.
A 42-year-old male patient, known case of decompensated alcoholic cirrhosis (Child C) with prior endoscopic band ligation sessions for bleeding esophageal varices in the last 3 years, currently listed for living donor liver transplantation, presented to the emergency department with torrential rectal bleeding associated with postural symptoms for one day. Physical examination revealed an alert patient, oriented to place, but not time with scleral icterus, pallor, tachycardia, diaphoresis and blood pressure was 88/60 mm Hg with grade 3 ascites and flapping tremors. Laboratory evaluation revealed hemoglobin 7.6 g/dL with serum bilirubin 12.8 mg/dL and international normalized ratio 2.1. One unit of packed red cells was transfused and intravenous terlipressin started. An urgent sigmoidoscopy was noncontributory in view of poor visualization due to fresh blood and clots. Transjugular intrahepatic portosystemic shunt was not ideal in view of advanced liver disease. A review of prior contrast imaging of the abdomen revealed large portosystemic shunt with afferent supply by inferior mesenteric vein through a shunt to the superior rectal vein (Figure 1A) forming large rectal varices; the efferent supply being internal iliac vein (Figure 1B). The large portosystemic shunt supplied the rectal variceal complex (Figure 1C, black arrow) through anterior, anterolateral and posterior tributaries (Figure 1C, arrows). In view of advanced liver disease status, failure to control bleed with traditional modality and complex shunt anatomy, interventional radiological approach was called for. A 7 Fr drainage catheter (Cook Medical, Bloomington) was inserted in right sub-diaphragmatic region to drain the ascites slowly and continuously. The left common femoral vein was punctured under ultrasound guidance and a 7 Fr sheath inserted. Using 5 Fr Internal Mammary (IM) catheter (Cordis, Fremont) right common iliac vein was cannulated and a 0.035” hydrophilic guidewire (Terumo, Tokyo) was passed into the right internal iliac vein. 5F IM catheter was exchanged for a 7 Fr pulmonary artery (PA) catheter (Edwards Lifesciences, California), which was placed in the right internal iliac vein. Venogram taken after inflating the PA catheter bulb showed good collateral flow between right and left internal iliac veins. Segment 5 branch of portal vein was then punctured using micro-puncture set (Cook Medical, Bloomington) and a 5 Fr sheath inserted and a 4 Fr Multipurpose catheter (Cook Medical, Bloomington) was advanced into the main portal vein. Venogram showed hepatofugal flow with predominant filling of inferior mesenteric vein. Venogram taken from the inferior mesenteric vein showed large shunt in pelvic region and associated rectal varices (Figure 2A, arrow; 2B, arrows respectively) draining predominantly into right internal iliac vein with reduction in shunt flow velocity on inflation of the right internal iliac balloon catheter. Keeping the balloon inflated (Figure 2C, white arrow), tributaries of the shunt (3 in number) were sequentially cannulated using 2.7 Fr Progreat microcatheter (Terumo, Tokyo) and embolized with N-butyl -2-Cyanoacrylate (Endocryl™, Endotech, Mumbai; Figure 2C, black arrow) keeping the balloon inflated. Post embolization venogram showed no residual filling of the varices (Figure 2D, arrows) and absence of systemic embolization. Post procedure portogram revealed hepatopetal flow with evidence of a partial chronic thrombus in main portal vein causing ~ 50% narrowing. Balloon was deflated and taken out. The hepatic tract was embolized using micro fiber coils (Boston Scientific, Massachussets) under fluoroscopy and ultrasound guidance. A plain computed tomography done 24 hr later revealed complete obliteration of rectal varices with glue cast formation (Figure 1D). Video 1 shows the real time procedural steps encompassing salient features of the interventional treatment.
Rectal variceal bleeding has been classically managed using band ligation, endoscopic sclerotherapy, surgery, TIPSS or interventional embolization. Norton et al suggested that in the event that the rectal entire varix cannot be banded, there would be risk of a wide defect in the varix after sloughing of the band leading to unsafe banding technique in case of large rectal varices. Common interventional modalities include double balloon occlusion, percutaneous transhepatic obliteration or balloon occluded transvenous obliteration (BRTO) using sclerosant. Based on shunt complexity, most of the conventional interventional option pose difficulty. Table 1 shows reported interventional approaches to management of rectal variceal bleeds in portal hypertension.[4-10] Endoscopic sclerotherapy and banding based occlusion of blood supply or main drainage routes is difficult, requiring multiple sessions for variceal eradication and TIPSS is effective in only select group of patients. The BRTO, is ineffective and difficult to perform when multiple drainage routes are involved and complete shunt tributary flow cannot be stopped with additional waiting time for sclerosant to obliterate the shunt. Use of coil-assisted (CARTO) shunt occlusion would have been technically difficult due to complex shunt anatomy, large number of coils and associated cost; plug-assisted (PARTO) shunt occlusion would have also been complicated in view of complex shunt anatomy. The use of cyanoacrylate glue proved much cheaper, shunt occlusion much faster and in the process, more beneficial. Before we commit to endoscopic management as the standard of care in bleeding rectal varices, the determination hemodynamics/shunt anatomy of rectal varices in each patient is important for selecting the most appropriate treatment modality. Our report is unique in many ways – one, we performed a demanding interventional procedure in a Child C cirrhotic, seldom reported in literature and two – we utilized balloon occlusion through retrograde transfemoral approach and used cyanoacrylate glue based embolization through the transhepatic anterograde route; all the while draining tense ascites – a complexity which is currently not described in literature.
With development in interventional procedures for portal hypertension and improved technical ease, newer studies/trials in management of ectopic variceal bleeding must consider interventional radiology procedures as possible first line of management in patients deemed as ‘difficult to control bleed’ or ‘difficult portal hemodynamic anatomy’.