Relationship of portal pressure, anorectal varices and hemorrhoids in cirrhotic patients

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Balloon-occluded antegrade transvenous obliteration of rectal varices: A case report

Patients with liver cirrhosis frequently experience rectal variceal bleeding subsequent to portal hypertension. Unlike gastroesophageal variceal bleeding, a well-established guideline does not exist in terms of management of bleeding rectal varices. A 75-year-old male with non-alcoholic-steatohepatitis induced cirrhosis presented with a 3-day history of severe rectorrhagia. Considering patient's clinical history, TIPS was not performed and thus, a novel endovascular technique termed balloon-occluded antegrade transvenous obliteration was considered. Under conscious sedation, an occlusion was made through balloon catheter by sclerotic agents including air/sodium tetradecyl sulfate/Lipiodol. After the procedure, and in the 6 months follow up period the patient's hemodynamic status was stable and he recovered without any serious complications. Balloon-occluded antegrade transvenous obliteration is a feasible and safe modality for treating rectal varices bleeding and could be used as an alternative approach in patients with contraindications to traditional treatments.

Collaterals in portal hypertension: anatomy and clinical relevance

Portal hypertension is a key pathophysiology of chronic liver diseases typified with cirrhosis or noncirrhotic portal hypertension. The development of collateral vessels is a characteristic feature of impaired portal hemodynamics. The paraumbilical vein (PUV), left gastric vein (LGV), posterior gastric vein (PGV), short gastric vein (SGV), splenorenal shunt (SRS), and inferior mesenteric vein (IMV) are major collaterals, and there are some rare collaterals. The degree and hemodynamics of collateral may affect the portal venous circulation and may compensate for the balance between inflow and outflow volume of the liver. Additionally, the development of collateral shows a relation with the liver function reserve and clinical manifestations such as esophageal varices (EV), gastric varices, rectal varices and the other ectopic varices, hepatic encephalopathy, and prognosis. Furthermore, there may be an interrelationship in the development between different collaterals, showing additional influences on the clinical presentations. Thus, the assessment of collaterals may enhance the understanding of the underlying pathophysiology of the condition of patients with portal hypertension. This review article concluded that each collateral has a specific function depending on the anatomy and hemodynamics and is linked with the relative clinical presentation in patients with portal hypertension. Imaging modalities may be essential for the detection, grading and evaluation of the role of collaterals and may help to understand the pathophysiology of the patient condition. Further investigation in a large-scale study would elucidate the basic and clinical significance of collaterals in patients with portal hypertension and may provide information on how to manage them to improve the prognosis as well as quality of life.

An Update: Portal Hypertensive Gastropathy and Colopathy

Complications of portal hypertension include portal hypertensive gastropathy and colopathy. These disorders may cause chronic or acute gastrointestinal bleeding. The diagnosis is made endoscopically; therefore, there is great variability in their assessment. Portal hypertensive gastropathy can range from a mosaic-like pattern resembling snakeskin mucosa to frankly bleeding petechial lesions. Portal hypertensive colopathy has been less well-described and is variably characterized (erythema, vascular lesions, petechiae). Treatment is challenging and results are inconsistent. Currently, available evidence does not support the use of beta-blockers for primary prevention. Further investigation of the pathogenesis, natural history, and treatment of these disorders is needed.

Successful Transjugular Intrahepatic Portosystemic Shunt with Embolization Subsequent to Endoscopic Variceal Band Ligation for Bleeding Anorectal Varices

Anorectal variceal bleeding is a rare occurrence; however, in such event, it could be fatal due to large size and high blood flow rate of varices. However, to date, there is no standardized treatment modality. Although endoscopic treatment can be provided, in cases of recurrent anorectal variceal bleeding, other therapeutic modalities for hemostasis are necessary. Here, we present a case of 58-year-old female patient with liver cirrhosis, who suffered from massive bleeding of anorectal varices. Endoscopic variceal band ligation was performed for primary hemostasis. Additionally, transjugular intrahepatic portosystemic shunt (TIPS) with embolization was performed to reduce the risk of rebleeding. Following the procedure, she had no further bleeding episodes, and the size of anorectal varices decreased, as seen on an abdomino-pelvic computed tomography. Our case illustrates the effectiveness of combined radiological intervention of TIPS with embolization after endoscopic hemostasis, for variceal obliteration and prevention of rebleeding.

Myofibrotic malformation vessels: unique angiodysplasia toward the progression of hemorrhoidal disease

Background

The etiology and pathogenesis of hemorrhoids is unclear, although hemorrhoids are a worldwide disease in men and women, with peak prevalence at 45–65 years of age. Hemorrhoidal cushions as the anal venous plexi are normal anatomical structures from infancy. This study attempts to reveal the angiodysplasia and other pathological changes in association with different degrees of symptomatic hemorrhoids.

Materials and methods

A total of 281 patients with internal hemorrhoids from degree I to IV underwent hemorrhoidectomy. The vascular changes were analyzed by microscopic assessment and software analysis, with Masson’s trichrome, CD34, and smooth muscle actin.

Results

The hemorrhoidal tissues exhibited abnormal vessels in the mucosae and submucosae that we termed them as myofibrotic malformation vessels (MMVs). MMVs are not ascribed to arteries or veins because they exhibit enlarged and tortuous lumens with smooth muscle dysplasia and fibrotic deposition in the walls without overlying mucosal ulceration. The muscularis mucosae also showed smooth muscle dysplasia and fibrosis, even if it were interrupted by the intruding MMVs. The statistical data indicated that the severity of all the changes correlate positively with the progression of hemorrhoids (P<0.001). Hemorrhoidal patients are prone for reoccurrence even with prolapsing hemorrhoid when compared with the conventional hemorrhoidectomy. Multiple logistic regression analysis showed that MMVs in mucosal propria, mean thickness of mucosal muscularis layer, and fibrotic changes in MMV were independent risk factors for MMVs in hemorrhoidal disease.

Conclusion

MMVs and muscularis mucosae dysplasia reciprocally contribute to hemorrhoidal exacerbation. The novel findings of this study propose that the characteristic features of MMVs and muscularis mucosae dysplasia of the anorectal tube ultimately cause symptomatic hemorrhoids, which could affect the clinical management of hemorrhoidal disease through the use of surgery to target the malformed vessels.

Treatment of ectopic varices with portal hypertension

Ectopic varices are unusual with portal hypertension and can involve any site along the digestive tract outside the gastroesophageal region. Hemorrhage from ectopic varices generally are massive and life threatening. Diagnosis of ectopic varices is difficult and subsequent treatment is also difficult; the optimal treatment has not been established. Recently, interventional radiology and endoscopic treatments have been carried out successfully for hemorrhage from ectopic varices.

Portal hypertensive gastropathy and colopathy

Portal hypertensive gastropathy (PHG) and colopathy (PHC) are considered complications of portal hypertension. Both entities are clinically relevant because they may cause insidious blood loss or even acute massive gastrointestinal hemorrhage. Endoscopic evaluation is necessary for the diagnosis of PHG and PHC. The existence of different endoscopic criteria for PHG and PHC makes consensus difficult and results in a broad range of reported prevalence. Therapy targeted at reduction of portal pressure and mucosal blood flow has been used to treat acute bleeding; nonselective β-blockers are the most frequently used agents. Further studies are needed to clarify the natural history, pathogenesis, and treatment of PHG and PHC.

Systematic review of anorectal varices

AIM

Anorectal varices are an uncommon, but significant, source of bleeding in patients with portal hypertension. The aim of this article was to review systematically the available literature on the aetiology, clinical presentation and management of anorectal varices, and to suggest a simple treatment algorithm based on available evidence and local expertise.

METHOD

A systematic literature search was carried out to identify articles on anorectal varices, and the search strategy identified 57 relevant references. The inclusion criteria included a consecutive cohort of patients having treatment for anorectal varices with details of success rates and the number of different techniques used. Exclusion criteria included papers published in languages other than English with no English version and results not reported separately for anorectal varices.

RESULTS

Anorectal varices can occur in up to 89% of patients with portal hypertension, although the overall incidence in the general population is low. Diagnosis is best achieved with anoscopy or flexible sigmoidoscopy. The current evidence supports the use of local procedures, such as endoscopic band ligation, to arrest bleeding where feasible, with radiological or surgical procedures used in the event of failure.

CONCLUSION

As there are no large series on this pathology, we present a systematic approach for the patient with anorectal varices.

Non-variceal gastrointestinal bleeding in patients with liver cirrhosis: a review

BACKGROUND

Non-variceal gastrointestinal (NVGI) bleeding in cirrhosis may be associated with life-threatening complications similar to variceal bleeding.

AIM

To review NVGI bleeding in cirrhosis.

METHODS

MEDLINE, Scopus, and ISI Web of Knowledge were searched, using the textwords "portal hypertensive gastropathy," "gastric vascular ectasia," "peptic ulcer," "Dieulafoy's," "Mallory-Weiss syndrome," "portal hypertensive enteropathy," "portal hypertensive colopathy," "hemorrhoids," and "cirrhosis."

RESULTS

Portal hypertensive gastropathy (PHG) and gastric vascular ectasia (GVE) are gastric lesions that most commonly present as chronic anemia; acute upper GI (UGI) bleeding is a rare manifestation. Management of PHG-related bleeding is mainly pharmacological, whereas endoscopic intervention is favored in GVE-related bleeding. Shunt therapies or more invasive techniques are restricted in refractory cases. Despite its high incidence in cirrhotic patients, peptic ulcer accounts for a relatively small proportion of UGI bleeding in this patient population. However, in contrary to general population, the pathogenetic role of Helicobacter pylori infection remains questionable. Finally, other causes of UGI bleeding include Dieulafoy's lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids. However, the vast majority of studies are case reports and, therefore, the incidence, diagnosis, and risk of bleeding remain undefined. Endoscopic interventions, shunting procedures, and surgical techniques have been described in this setting.

CONCLUSIONS

The data on NVGI bleeding in liver cirrhosis are surprisingly scanty. Large, multicenter epidemiological studies are needed to better assess prevalence and incidence and, most importantly, randomized studies should be performed to evaluate the success rates of therapeutic algorithms.

[Endoscopic findings and clinical significance of portal hypertensive colopathy]

BACKGROUND/AIMS

The endoscopic findings and clinical relevance of portal hypertensive colopathy are not well described in Korea. We aimed to do a retrospective study of mucosal changes in the colon of patients with liver cirrhosis and to find their association with clinical characteristics.

METHODS

We reviewed the clinical data and endoscopic findings of 48 patients with liver cirrhosis and 48 patients, matched for age and sex, with irritable bowel disease (IBS) who underwent colonoscopy over a 5 year span.

RESULTS

Patients with liver cirrhosis were more likely to have colitis-like lesions and vascular abnormalities than IBS patients. Low platelet count (p=0.005) and severe esophageal varices (p=0.011) were associated with portal hypertensive colopathy, whereas the etiologies and severity of cirrhosis were not associated with these findings.

CONCLUSIONS

Portal hypertensive colopathy can be defined with colitis-like lesions or vascular lesions. These lesions are more frequently present in patients with more severe esophageal varices and thrombocytopenia.

Endoscopic band ligation of internal haemorrhoids versus stapled haemorrhoidopexy in patients with portal hypertension

BACKGROUND AND STUDY AIM

Portal hypertension is common in Egypt as a sequela to the high prevalence of hepatitis C virus and bilharziasis. In portal hypertension internal haemorrhoids are frequently found. The aim of this work was to compare the outcome of endoscopic band ligation (EBL) of symptomatic internal haemorrhoids with that of stapled haemorrhoidopexy (SH) in Egyptian patients with portal hypertension.

PATIENTS AND METHODS

In this study, 26 portal hypertensive patients (with oesophageal and/or fundal varices) with a grade 2-4 internal haemorrhoids who had no coagulation disorders were randomised to treatment by EBL (13 patients) or SH (13 patients) after doing colonoscopy. Symptom scores of bleeding and prolapse were assessed before and after the intervention. Complications were recorded. Patients were followed up for 12months.

RESULTS

Goligher's grades of internal haemorrhoids improved significantly (p=0.018) 12weeks after SH (from 2.9±0.8 to 0.4±0.5; p=0.001) and after EBL (from 2.8±0.8 to 1.1±0.8; p=0.001). Symptom (bleeding and prolapse) scores significantly improved 4weeks after both EBL (from 1.6±0.8 to 0.6±0.8; p<0.001 and from 1.6±0.9 to 0.5±0.5; p=0.002, respectively) and SH (from 1.8±0.8 to 0.2±0.4; p=0.002 and from 1.5±0.9 to 0.2±0.4; p=0.001, respectively). The differences after 4weeks between EBL and SH were not significant (p=0.168 and p=0.225). Pain requiring analgesics occurred in five patients (38.5%) after EBL, compared with six (46.2%) after SH (p=0.691). Minimal bleeding occurred in two patients (15.4%) after EBL but not with SH; urinary retention was observed in one patient after EBL compared with two after SH; and anal fissures were observed in one patient after EBL. During 1-year follow-up, increased frequency of stool occurred in one patient after EBL. Recurrence of symptoms was observed in three patients after EBL and in one after SH.

CONCLUSION

For portal hypertensive patients with internal haemorrhoids and without coagulation disorders SH seems to be superior to EBL. However further studies are needed to evaluate EBL in different grades of cirrhosis.

Clinicopathological features and treatment of ectopic varices with portal hypertension

Bleeding from ectopic varices, which is rare in patients with portal hypertension, is generally massive and life-threatening. Forty-three patients were hospitalized in our ward for gastrointestinal bleeding from ectopic varices. The frequency of ectopic varices was 43/1218 (3.5%) among portal hypertensive patients in our ward. The locations of the ectopic varices were rectal in thirty-two, duodenal in three, intestinal in two, vesical in three, stomal in one, and colonic in two patients. Endoscopic or interventional radiologic treatment was performed successfully for ectopic varices. Hemorrhage from ectopic varices should be kept in mind in patients with portal hypertension presenting with lower gastrointestinal bleeding.

Retrospective analysis of endoscopic injection sclerotherapy for rectal varices compared with band ligation

BACKGROUND AND AIMS

The study's aim was to evaluate the efficacy of endoscopic injection sclerotherapy (EIS) compared with endoscopic band ligation (EBL) in treating rectal varices.

METHODS

Data from 34 consecutive patients who underwent endoscopic treatments for rectal varices were analyzed. The clinical outcomes, including complications, related to EIS or EBL retrospectively.

RESULTS

In 25 of the 34 patients, EIS was performed weekly 2-5 times (mean, 2.7), and the total amount of sclerosant ranged from 3.2 to 12.0 mL (mean, 5.2 mL). After EIS, colonoscopy revealed shrinkage of the rectal varices in all 25 patients, with no complications reported. In 9 of the 34 patients, EBL was performed weekly 1-3 times (mean, 2.2), and bands were placed on the varices at 2-12 sites (mean, 8.0). After EBL, colonoscopy revealed ulcers and shrinkage of the rectal varices in all nine patients, eight of whom experienced no operative complications. The overall recurrence rate for rectal varices was 10 of 24 (41.7%), including 5 of 9 (55.6%) receiving EBL and 5 of 15 (33.3%) receiving EIS, over a 1-year follow-up period (n = 24). All four patients with recurrence of bleeding were EBL cases, versus no EIS cases (P < 0.05).

CONCLUSION

EIS appears superior to EBL with regard to effectiveness and complications after endoscopic treatment of rectal varices.

Portal hypertensive colopathy is associated with portal hypertension severity in cirrhotic patients

AIM: To assess the prevalence of portal hypertension (PH) related colorectal lesions in liver transplant candidates, and to evaluate its association with the severity of PH.

METHODS: Between October 2004 and December 2005, colonoscopy was performed in 92 cirrhotic liver transplant candidates. We described the lesions resulting from colorectal PH and their association with the grade of PH in 77 patients who underwent measurement of hepatic venous pressure gradient (HVPG).

RESULTS: Mean age was 55 years and 80.7% of patients were men. The main etiology of cirrhosis was alcoholism (45.5%). Portal hypertensive colopathy (PHC) was found in 23.9%, colonic varices in 7.6% and polyps in 38% of patients (adenomatous type 65.2%). One asymptomatic patient had a well-differentiated adenocarcinoma. The manifestations of colorectal PH were not associated with the etiology of liver disease or with the Child-Pugh grade. Ninety percent of patients with colopathy presented with gastroesophageal varices (GEV), and 27.5% of patients with GEV presented with colopathy (P = 0.12). A relationship between higher values of HVPG and presence of colopathy was observed (19.9 ± 6.2 mmHg vs 16.8 ± 5.4 mmHg, P = 0.045), but not with the grade of colopathy (P = 0.13). Preneoplastic polyps and neoplasm (P = 0.02) and spontaneous bacterial peritonitis (P = 0.006) were more prevalent in patients with colopathy. We did not observe any association between previous β-blocker therapy and the presence of colorectal portal hypertensive vasculopathy.

CONCLUSION: PHC is common in cirrhotic liver transplant candidates and is associated with higher portal pressure.

Evaluation of therapeutic effects on rectal varices using percutaneous color Doppler ultrasonography

AIM

We report the usefulness of percutaneous color Doppler ultrasonography (CDU) for evaluating therapeutic effects on rectal varices.

METHODS

Ultrasonographic examination and color flow imaging were performed using a color Doppler unit (Aplio 50 or XV, Toshiba, Tokyo, Japan) with a 3.5 MHz convex probe. We performed endoscopic injection sclerotherapy (EIS) for rectal varices in seven patients and partial splenic arterial embolization (PSE) for hypersplenism in four. We examined color flow images and measured the velocity of blood flow in rectal varices using fast-Fourier transform analysis by CDU in all eleven patients, before and after treatments.

RESULTS

Rectal varices were detected by Doppler color flow imaging in all eleven patients before treatments. Blood flowvelocity in the rectal varices ranged from 5.7-11.6 cm/s (mean 8.6 cm/s). Rectal varices were observed in all patients by colonoscopy; enlarged, tortuous large varices with red color sign in nine and enlarged, tortuous large varices without red color in two. Seven days after EIS or PSE, CDU showed an extreme decrease in blood flow in all eleven rectal varices, compared to values before EIS or PSE.

CONCLUSIONS

CDU can be performed repeatedly and is useful for evaluating the therapeutic effects of treatments for rectal varices.

[Results of colonoscopic examination in the evaluation of cirrhotic candidates for liver transplantation]

AIM

To assess the presence of preneoplastic and neoplastic colonic lesions, as well as those related to portal hypertensive vasculopathy, and their association with liver disease in cirrhotic patients who are candidates for orthotopic liver transplantation (LT).

METHODS

Between October 2004 and December 2005, colonoscopy was performed in 92 patients who were LT candidates, aged >50 years old or aged <50 years old but with clinical indications.

RESULTS

Eighty-eight percent of the patients were > 50 years old, the mean age was 55.3 years (29-69) and 81.5% were males. The main etiology of cirrhosis was alcoholic (46.7%), and 21% were Child-Pugh class A. No abnormalities were detected in 20.7%. Polyps were discovered in 38% (35/92) of patients (adenomatous 65.2%; tubular type 86.7%). Six patients with adenomatous polyps had mild dysplasia, and one asymptomatic patient had a well-differentiated adenocarcinoma. An association was found between polyps and male sex (44% males vs 17.6% females; p=0.044) and Child-Pugh grade (63.2% Child A vs 32.9% Child B/C, p=0.016) but not with serum levels of carcinoembryonic antigen (CEA), age or etiology of liver disease. Portal hypertensive colopathy was found in 23.9%, rectal varices in 7.6% and internal or mixed hemorrhoids in 52.3%.

CONCLUSION

The prevalence of preneoplastic and neoplastic colonic lesions may support the use of colonoscopy in LT candidates aged >50 years-old or with a history suggesting lower gastrointestinal bleeding or other abnormalities.

Transverse colonic varices successfully treated with endoscopic procedure

A 75-year-old woman with hepatitis C virus antibody-positive liver cirrhosis was admitted to our hospital with anal bleeding. Colonoscopy revealed red color-positive tortuous transverse colonic varices near the splenic flexure. Colonic varices were considered to be the most probable cause of bleeding, although the precise site could not be determined. Endoscopic injection sclerotherapy was performed for colonic varices. Endoscopic clipping was performed for bilateral sites of varices as an additional treatment. Four months after endoscopic treatments, colonoscopy revealed ulcer scars in the transverse colon and shrinkage of the varices.

Diagnosis of rectal varices via color Doppler ultrasonography

OBJECTIVES

There has been no report on the hemodynamic evaluation of rectal varices by percutaneous color Doppler ultrasonography. Here, we report the usefulness of color Doppler ultrasonography for this purpose.

METHODS

Color Doppler ultrasonography was performed in 44 patients: 31 patients with portal hypertension, 7 with liver cirrhosis (LC) without portal hypertension, and 6 non-LC patients. We examined color flow images and measured velocity of blood flow in rectal varices using fast-Fourier transform (FFT) analysis. Next, we performed colonoscopy on these 44 patients as follow-up to confirm findings by color Doppler. Endoscopic findings of rectal varices were evaluated according to the grading system outlined in "The General Rules for Recording Endoscopic Findings of Esophageal Varices" prepared by the Japanese Research Committee on Portal Hypertension.

RESULTS

Rectal varices were shown by Doppler color flow images in 27 of the 31 patients (87.1%) with portal hypertension. Blood flow velocity in those 27 rectal varices ranged from 2.0 to 11.6 cm/s (mean 6.5 +/- 2.4 cm/s). Rectal varices were observed in all 27 of these cases by colonoscopy. On the other hand, rectal varices were not observed by colonoscopy in the 7 LC patients without portal hypertension and the 6 non-LC patients not shown to have rectal variceal blood flow via color Doppler ultrasonography. Sensitivity, specificity, and accuracy were 27/27 (100%), 17/17 (100%), 44/44 (100%), respectively, for detection of rectal varices with color Doppler ultrasonography. Next, we compared velocities of rectal varices obtained by color Doppler ultrasonography with colonoscopic findings. Mean velocity (7.1 +/- 2.3 cm/s) in Cb variceal cases (N = 20) was significantly higher than that (4.9 +/- 1.7 cm/s) in the Cw rectal variceal cases (N = 7) (P < 0.05). Mean velocity (8.5 +/- 2.0 cm/s) in the RC-positive cases (N = 9) was significantly higher than that (5.4 +/- 1.8 cm/s) in RC-negative cases (N = 18) (P < 0.01). Mean velocity (9.8 +/- 1.6 cm/s) in rectal bleeding cases (N = 3) was significantly higher than that (6.1 +/- 2.1 cm/s) in patients without bleeding (N = 24) (P < 0.05). Seven days after endoscopic injection sclerotherapy (EIS) treatment, color Doppler ultrasonography showed an extreme decrease in blood flow in all three rectal varices in comparison with values before EIS.

CONCLUSIONS

Color Doppler ultrasonography can be considered a very useful noninvasive tool for diagnosis of rectal varices.

Stapled hemorrhoidopexy for prolapsed hemorrhoids in patients with liver cirrhosis; a preliminary outcome for 8-case experience

PURPOSE

To investigate the efficacy and safety of stapled hemorrhoidopexy in treating prolapsed hemorrhoids in patients with liver cirrhosis.

PATIENTS AND METHODS

Eight consecutive cases of patients with prolapsed hemorrhoids comorbid with liver cirrhosis, who had intractable response to other interventions, were enrolled in this retrospective study between January 2002 and June 2006 at our institute. Six patients (75%) had Child-Pugh class A liver cirrhosis, whereas only two patients (25%) had class B disease. Rectal varices were identified in three patients (37.5%), and esophageal varices were identified in six patients (75%). Concurrent rectal and esophageal varices existed in three patients (37.5%). The patients underwent stapled hemorrhoidopexy with Proximate PPH-03 in a lithotomy position under spinal/intravenous general anesthesia.

RESULTS

There was no procedure-related mortality or major complications except hemorrhage. Two patients (25%) were complicated with postoperative staple-line bleeding, which was managed with conservative treatment without reoperation. There were no leading symptoms of relapsing during a follow-up period of at least 6 months.

CONCLUSIONS

This study may prove that stapled hemorrhoidopexy is a feasible and safe approach for prolapsed hemorrhoids concurrent with liver cirrhosis.

Hemodynamic evaluation of rectal varices by color Doppler ultrasonography: a case report

A 69-year-old man with liver cirrhosis was admitted to our hospital with general fatigue. Colonoscopy revealed risky red color sign-positive enlarged tortuous rectal varices. Endoscopic injection sclerotherapy (EIS) was performed three times weekly using 5% ethanolamine oleate with iopamidol; the total amount of sclerosant was 7 ml. Images of rectal varices and the outflowing vessel from rectal varices were obtained via color Doppler ultrasonography before EIS, and fast Fourier transform analysis showed a continuous flow with a frequency shift of 276.6 Hz. We successfully performed EIS for this patient, having effective varicealography. After EIS, colonoscopy revealed shrinkage of the varices in the rectum, and color Doppler indicated an extreme decrease of blood flow in the rectal varices. In conclusion, color Doppler is a useful noninvasive modality for detecting rectal varices and for evaluating the therapeutic effects of EIS.

Evaluation of the hemodynamics of rectal varices by endoscopic ultrasonography

BACKGROUND

The usefulness of endoscopic color Doppler ultrasonography (ECDUS) for evaluating hemodynamics is examined in 12 cases of rectal varices. We also evaluate the safety of endoscopic therapies in rectal variceal patients.

METHODS

ECDUS was performed for 12 rectal variceal patients with a 7.5-MHz convex-type Pentax FG-32UA system. A Hitachi EUB 525 was used for the display. ECDUS provides a color display of blood flow, and calculates the velocity using a fast-Fourier transform analysis. We monitored the color flow images and measured blood flow velocity in rectal varices. Then, we evaluated the velocity of 350 F2-type esophageal varices via ECDUS, and compared the velocities between rectal varices and esophageal varices.

RESULTS

Color flow images of rectal varices and of inflow vessels to rectal varices were obtained in all 12 patients with ECDUS. The mean velocity of F2-type rectal varices was 5.5 +/- 1.3 cm/s (n = 12), while the mean velocity of F2 esophageal varices was 8.4 +/- 3.1 cm/s (range, 4.5-12.5 cm/s) (n = 350) via ECDUS. The velocities in rectal varices were lower than those in esophageal varices. Endoscopic injection sclerotherapy (EIS) was successfully performed in five red-color-sign-positive rectal variceal patients having a mean velocity 5.4 +/- 1.1 cm/s.

CONCLUSIONS

The velocities of rectal varices were lower than those of esophageal varices. Evaluation of the hemodynamics of rectal varices is important for determining the appropriate therapeutic option. EIS is an effective therapy in cases of slow variceal flow. ECDUS is a necessary tool for effective and safe EIS for rectal varices.

An endoscopic injection with N-butyl-2-cyanoacrylate used for colonic variceal bleeding: a case report and review of the literature

We report a 64-yr-old patient with liver cirrhosis and bleeding esophageal varices that were obliterated by repeated endoscopic sclerotherapy. Eleven years later, he developed a massive, life-threatening rectosigmoid variceal hemorrhage. An endoscopic injection with N-butyl-2-cyanoacrylate (Histoacryl), performed over the rectosigmoid varices, achieved temporary hemostasis. The etiology, prevalence, relationship with portal hypertension, diagnosis, and treatment of colorectal varices are discussed.

Transjugular intrahepatic portosystemic shunt for bleeding angiodysplasia-like lesions in portal-hypertensive colopathy

Portal-hypertensive colopathy has attracted interest in recent years because such lesions can cause life-threatening hemorrhage. In contrast to upper gastrointestinal bleeding from varices, there is no established therapy for bleeding from angiodysplasia-like lesions. This case report describes the first successful use of transjugular intrahepatic portosystemic shunt (TIPS) for long-term control of bleeding from angiodysplasia-like colonic lesions in a patient with cirrhosis caused by chronic hepatitis B infection. During an 18-month course after TIPS, angiodysplasia-like lesions disappeared without any further evidence of recurrent hematochezia. TIPS may be helpful as second-line treatment in patients with recurrent portal-hypertensive bleeding from colonic angiodysplasia-like lesions who do not tolerate or are unresponsive to treatment with beta-adrenergic blockers.

Portal hypertensive colopathy in patients with cirrhosis

BACKGROUND

Colonic vascular ectasias and colorectal varices have been observed in patients with cirrhosis. However, the pathogenesis of these vascular lesions has not been established.

METHODS

We enrolled 35 cirrhotic patients and 20 normal controls in this study. All received colonoscopic examinations and measurements of plasma glucagon levels. Portal pressure measurements were performed in all the cirrhotic patients.

RESULTS

Colonic vascular ectasias occurred more commonly in cirrhotic patients than in controls (17 of 35 versus 0 of 20; p = 0.009) and more commonly in cirrhotic patients with ascites than in those without (15 of 24 versus 2 of 11; p = 0.038). However, the presence of colonic vascular ectasias was not related to the hepatic venous pressure gradient or plasma glucagon levels. Colorectal varices also occurred more commonly in cirrhotic patients than in controls (16 of 35 versus of 1 of 20; p = 0.034), but the hepatic venous pressure gradient, plasma glucagon levels, and severity of cirrhosis were not related to the presence of colorectal varices.

CONCLUSIONS

Portal hypertension per se and increased plasma glucagon levels may not play an important role in the pathogenesis of colonic vascular ectasias or colorectal varices in patients with cirrhosis.

Liver disease

Images