Massive lower gastrointestinal bleed due to rectal varix

Abstract

IntroductionMassive lower gastrointestinal bleeding is an importantmedical emergency. Among the causes of lower gastroin-testinal bleed, variceal bleeding due to rectal varices israre. Rectal varices frequently develop in patients withportal hypertension and represent porto-systemic collater-als. We present a case of bleeding rectal varices in a patientwith extrahepatic portal vein obstruction that was managedby N-butyl-2-cyanoacrylate injection, which was obliter-ated as documented on endosonography.Case detailsA 26-year-old male patient presented with massive lowergastrointestinal bleeding. On examination, he was palewith splenomegaly, but hemodynamically stable. His hae-moglobin was 3.8 g/dL, and other blood investigationswere in the normal range. Packed red blood cells weretransfused. Abdominal imaging showed splenomegaly withportal cavernoma suggesting the aetiology of extrahepaticportal venous obstruction (EHPVO) and rectal varices(Figs. 1, 2). Colonoscopy showed rectal varices (Fig. 3a)with evidence of blood flow on endosonography (Fig. 4a).Two millilitres of N-butyl-2-cyanoacrylate was injectedinto rectal varices with no post procedural complications(Fig. 3b, c; Video 1 of Electronic supplementary material).The bleeding had stopped. Three days after injection,repeat sigmoidoscopy showed a small ulcer in the rectum atthe injected site. Repeat endorectal ultrasound showedobliteration of the varices and their feeding vessels, withevidence of glue seen in the varix (Fig. 4b). The patient isunder follow-up for 3 months without any re-bleeding. Hishypercoagulation work-up including protein C, protein Slevels, antiphospholipid antibodies, factor V Leiden levelswas negative.DiscussionRectal varices result from dilatation of submucosal veinsthat extend from the dentate line proximally into the rec-tum, and represent the porto-systemic collaterals between