Rectal Variceal Bleeding in a Cirrhotic Patient with Peptic Ulcer Disease

Abstract

Purpose: Cirrhosis is a known sequelae of chronic liver disease. Complications include ascites, encephalopathy, and bleeding varices. Esophageal varices are the most commonly encountered type of bleed, with estimated mortality from first episode approaching 30-50%. Bleeding ectopic varices can be a rare form of GI bleed in cirrhotics. We present a case of a 57-year-old man with a history of hepatitis C cirrhosis who presented with melena and coffee ground emesis. Initial laboratory values were notable for hemoglobin 9.9 g/dL, platelets 158 K/UL, BUN 55 mg/dL, serum Cr 1.7 mg/dL, total bilirubin 1.8 mg/dL, AST 36 U/L, ALT 27 U/L, and INR 1.4. While in the ER he was noted to have 4-5 episodes of coffee ground emesis with a drop in hemoglobin by 2 gm. He was transfused packed red blood cells (PRBCs), started on Protonix and octreotide drips, and underwent emergent esophagogastroduodenoscopy (EGD). The EGD revealed two small columns of non-bleeding esophageal varices, esophagitis, a clean-based ulcer in the antrum, and an oozing 2-3 cm ulcer with a visible vessel in the second portion of the duodenum, treated with epinephrine injections and gold-probe cautery. Later that day, his mental status deteriorated and he developed hypotension with a drop in hemoglobin. After endotracheal intubation, initiation of pressor, and transfusions support, a second EGD was performed. The previously bleeding ulcer was again bleeding, and was treated with epinephrine injections and two endo-clips. Over the next hospital day, his hemoglobin stabilized between 8-9 g/dL and he was weaned off pressors. On the fourth day, he again became hypotensive, and developed hematochezia. A third EGD revealed the same duodenal ulcer, this time with no stigmata of bleeding. Using the same gastroscope, a flexible sigmoidoscopy was performed, revealing a large rectal varix with a fibrin clot (“nipple sign”). Banding was not attempted due to the very large nature of the varix. The patient subsequently underwent a transjugular intrahepatic portosystemic shunt procedure (TIPS). He was stable after TIPS, and only required a transfusion of one unit of PRBCs transfusion. Unfortunately, his condition deteriorated in the following days, and he succumbed to sepsis and multi-organ failure. There are important points that this case highlights. First, peptic ulcer disease is the most common etiology of upper GI bleeding. Second, the management of a brisk lower GI bleed, affecting hemodynamics, is EGD first. Third, TIPS is the appropriate management for bleeding ectopic varices.