1963 Non-Cirrhotic Hepatocellular Carcinoma Presenting as Bleeding Rectal Varices

Abstract

INTRODUCTION: Anorectal sources account for 15–20% of hospital admissions for acute lower gastrointestinal bleeding (LGIB). Rectal varices are common in patients with portal hypertension, however, clinically significant bleeding occurs in only 0.5–5%. Management of rectal varices is described in several case reports but no standardized therapy exists due to the low incidence. Here we describe a case rectal varices treated by collateral vein embolization during an initial presentation for noncirrhotic hepatocellular carcinoma. CASE DESCRIPTION/METHODS: A 69-year-old African American male presented for weakness in the setting of 3 days of hematochezia. Medical history was notable for prostate cancer status post radiation therapy, prior hepatitis B exposure and hepatitis C status post Harvoni with sustained virologic response. Physical examination was notable for normal vital signs and gross blood on glove during rectal exam. Labs revealed a hemoglobin of 11.6 g/dl, and BUN of 18.0 mg/dl. CT abdomen was performed and notable for asymmetric rectal wall thickening, an ill-defined mass at the hepatic dome and expansion of the portal veins. He was admitted for colonoscopy in the setting of hematochezia. Liver MRI was completed, showing an abnormal heterogeneous right hepatic lobe with extensive portal vein thrombus and a 1.1 cm exophytic nodular LI-RADS 5 lesion. Tumor markers were notable for a normal CEA, and an Alpha-1-fetoprotein of >55,000 ng/ml. Colonoscopy was performed to evaluate the rectal findings on CT, revealing large rectal varices with a prominent nipple sign. Interventional radiology (IR) was consulted for embolization of a venous shunt draining bilateral hemorrhoidal veins and obtained a liver biopsy, resulting in grade II-III Hepatocellular carcinoma (HCC). Patient would ultimately fail sorafenib and lenvatinib therapy due to liver toxicity and continued tumor growth without recurrence of LGIB. DISCUSSION: HCC in the absence of cirrhosis has been documented in several patient populations to include chronic hepatitis B and more recently NASH. Portal vein thrombosis (PVT) is common in HCC with an incidence of 34–50%, and frequently leads to varix formation. Rectal varices are less common than esophageal and gastric varices, however can still result in life threatening hemorrhage. Given the low incidence, there are no established guidelines to define management strategies for bleeding rectal varices. Currently long term management is directed by physician expertise and available services.