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Refractory rectal variceal bleeding treated with EUS-guided coil embolization
Surinder Singh Rana1, Ravi Sharma1, Rajesh Gupta2
1 Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| Date of Submission | 19-Apr-2020 |
| Date of Acceptance | 24-Aug-2020 |
| Date of Web Publication | 21-Dec-2020 |
Correspondence Address:
Surinder Singh Rana,
Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/eus.eus_63_20 PMID: 33353904
A 54-year-old male, known case with alcohol-related decompensated cirrhosis of the liver with portal hypertension and ascites, presented with recurrent episodes of rectal bleeding to a local hospital. He was resuscitated, received packed red blood cells transfusion and fresh frozen plasma and underwent proctoscopy with multiple sessions of sclerotherapy for rectal hemorrhoids. However, rectal bleeding persisted and sigmoidoscopy revealed bleeding rectal varices. Two milliliters of N-butyl 2-cyanoacrylate glue were injected into rectal varix and bleeding subsided. However, rectal bleeding recurred 2 weeks later and colonoscopy did not reveal any active bleeding lesion in the colon and rectal varix at site of glue injection was found to be thrombosed. No soft vascular lesion could be identified in the rectum on probing with closed biopsy forceps. Therefore, the patient was referred to our center for EUS.
Rectal EUS revealed a column of patent rectal varix with good flow on Doppler reaching up to the mucosa [Figure 1]a. Under EUS guidance, the rectal varix was punctured with a 22 G needle and position confirmed by aspirating blood. Thereafter, a single coil of 8 mm diameter (Nester Embolisation Coil; Wilson Cook Medical, Winston-Salem, North Carolina) was deployed into the rectal varix under EUS guidance [Figure 1]b. Postprocedure EUS revealed absence of flow in rectal varix on color Doppler confirming obliteration of rectal varix [Figure 1]c and abdominal X-ray demonstrated the metallic coil in the pelvis [Figure 2]. There were no immediate postprocedure complications and there has been no recurrence of rectal bleeding after a 3-month follow-up. | Figure 1. (a) Rectal EUS: column of patent rectal varix with good flow on Doppler reaching up to the mucosa (arrows) (b) EUS guided coil injection into rectal varix (arrows) (c) Post-procedure EUS: absence of flow in rectal varix on colour doppler confirming obliteration of rectal varix (arrows)
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 | Figure 2. Post procedure abdominal X Ray: Metallic coil in pelvis (arrows) (a) Antero-posterior view (b) lateral view
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Rectal varices are a rare cause of rectal bleeding in patients with portal hypertension and are distinct from hemorrhoids being present more than 4 cm above the anal verge and not having any continuity with anal columns and pectinate line.[1] Bleeding rectal varices are usually visible endoscopically, but occasionally, they are not visible on endoscopy and can be visualized and managed by EUS.[1],[2] EUS-guided cyanoacrylate glue or coil injection or combination of both have been described as successful therapeutic option in patients with both endoscopically visible as well as inevident rectal varices.[1],[2],[3]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Philips CA, Augustine P. Endoscopic ultrasound-guided management of bleeding rectal varices. ACG Case Rep J 2017;4:e101.  |
| 2. | Sharma M, Somasundaram A. Massive lower GI bleed from an endoscopically inevident rectal varices: Diagnosis and management by EUS (with videos). Gastrointest Endosc 2010;72:1106-8. |
| 3. | Messallam AA, Kumbhari V, Saxena P, et al. Large bleeding rectal varices treated with endoscopic ultrasound-guided coiling and cyanoacrylate injection. Endoscopy 2014;46 Suppl 1 UCTN:E28-9. |
[Figure 1], [Figure 2]
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