Anorectal varices

Anorectal varices are the dilation of collateral submucosal vessels due to backflow in the veins of the rectum.[1] Typically this occurs due to portal hypertension which shunts venous blood from the portal system through the portosystemic anastomosis present at this site into the systemic venous system.[2][3] This can also occur in the esophagus, causing esophageal varices, and at the level of the umbilicus, causing caput medusae.[4] Between 44% and 78% of patients with portal hypertension get anorectal varices.[3][5]

Anorectal varices
SpecialtyGastroenterology

Pathogenesis

Blood from the superior portion of the rectum normally drains into the superior rectal vein and via the inferior mesenteric vein to the liver as part of the portal venous system. Blood from the middle and inferior portions of the rectum is drained via the middle and inferior rectal veins. In portal hypertension, venous resistance is increased within the portal venous system; when the pressure in the portal venous system increases above that of the systemic, blood is shunted through the portosystemic anastomoses. The shunting of blood and consequential increase of pressure through the collateral veins causes the varicosities.

Diagnosis

The terms rectal varices and haemorrhoids are often used interchangeably, but this is not correct.[6] Haemorrhoids occur due to prolapse of the rectal venous plexus and are no more common in patients with portal hypertension than those without.[7] Rectal varices, however, are only found in patients with portal hypertension and are common in conditions such as cirrhosis.[8]

Treatment

Unlike esophageal varices, rectal varices are less prone to bleeding, are less serious when a bleed does occur, and are easier to treat because of the more accessible location.[9]

Typically, treatment consists of addressing the underlying portal hypertension. Some treatments include portosystemic shunting, ligation, and under-running suturing.[5] Insertion of a transjugular intrahepatic portosystemic shunt (TIPS) has been shown to alleviate varices caused by portal hypertension.[1] Successful treatment of portal hypertension that subsequently reduces anorectal varices provides a confirmation of the initial diagnosis, allowing for a distinction between varices and hemorrhoids, which would not have been alleviated by reduction of portal hypertension.

References
  1. Katz, JA; Rubin, RA; Cope, C; Holland, G; Brass, CA (Jul 1993). "Recurrent bleeding from anorectal varices: successful treatment with a transjugular intrahepatic portosystemic shunt". The American Journal of Gastroenterology. 88 (7): 1104–7. PMID 8317414.
  2. Hunt AH. 'A contribution to the study of portal hypertension. Edinburgh: Livingstone, 1958: 61.
  3. Chawla, Y; Dilawari, J B (1 March 1991). "Anorectal varices--their frequency in cirrhotic and non-cirrhotic portal hypertension". Gut. 32 (3): 309–311. doi:10.1136/gut.32.3.309. PMC 1378841. PMID 2013427.
  4. Moubarak, Elie; Bouvier, Antoine; Boursier, Jérôme; Lebigot, Jérôme; Ridereau-Zins, Catherine; Thouveny, Francine; Willoteaux, Serge; Aubé, Christophe (15 October 2011). "Portosystemic collateral vessels in liver cirrhosis: a three-dimensional MDCT pictorial review". Abdominal Imaging. 37 (5): 746–766. doi:10.1007/s00261-011-9811-0. PMID 22002160.
  5. Hosking, SW; Smart, HL; Johnson, AG; Triger, DR (1989-02-18). "Anorectal varices, haemorrhoids, and portal hypertension". Lancet. 1 (8634): 349–52. doi:10.1016/s0140-6736(89)91724-8. PMID 2563507.
  6. McCormack TT BHSJJA. Rectal varices are not piles. Br J Surg. Fev 1984;71(2):163.
  7. Jacobs DM, Bubrick MP, Onstad GP, Hitchcock CR. The relationship of haemorrhoids to portal hypertension. Dis Col Rect 1980:23(8):567-9.
  8. Zuberi FF ZBKMKM. Frequency of rectal varices in patients with cirrhosis. J Coll Physicians Surg Pak. Feb 2004;14(2):94-7.
  9. Johansen K. Bardin J. Orloff MJ. Massive bleeding from hemorrhoidal varices in portal hypertension. JAMA 1980:224 (18): 2084-5.
Classification
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