Endoscopic ultrasonographic evaluation of the rectum in cirrhotic portal hypertension

Use of TC-325 Hemostatic Powder as a Rescue Monotherapy for Management of Rectal Variceal Bleed

The use of the endoscopic hemostatic powder TC-325 as a rescue monotherapy or as an adjunct agent in achieving hemostasis has been studied in upper gastrointestinal variceal bleeds and nonvariceal lower gastrointestinal bleeds with promising results. In this report, we describe a case of a successful use of TC-325 as rescue monotherapy to manage rectal variceal bleeding in a patient with alcohol-related cirrhosis with no report of bleeding recurrence and no side effects within the first 7 days, 30 days, or 6 months.

Endoscopic ultrasound-guided vascular interventions: An expanding paradigm

Endoscopic ultrasound (EUS) has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal (GI) diseases. The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions. EUS provides important clinical and anatomical information related to the vessels' size, appearance and location. Its excellent spatial resolution, use of colour doppler with or without contrast enhancement and ability to provide images "real-time" helps in precision while intervening vascular structures. Additionally, structures such as venous collaterals or varices can be dealt with optimally using EUS. EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension. It also helps to avoid radiation exposure in addition to being minimally invasive. These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions. EUS-guided portal vein (PV) access and therapy is a new kid on the block. EUS-guided portal pressure gradient measurement, injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology. Lastly, EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus. Herein, we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding, portal vein access and its related therapeutic interventions, cardiac access, and therapy. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.

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.

Management of rectal varices in portal hypertension

Rectal varices are portosystemic collaterals that form as a complication of portal hypertension, their prevalence has been reported as high as 94% in patients with extrahepatic portal vein obstruction. The diagnosis is typically based on lower endoscopy (colonoscopy or sigmoidoscopy). However, endoscopic ultrasonography has been shown to be superior to endoscopy in diagnosing rectal varices. Color Doppler ultrasonography is a better method because it allows the calculation of the velocity of blood flow in the varices and can be used to predict the bleeding risk in the varices. Although rare, bleeding from rectal varices can be life threatening. The management of patients with rectal variceal bleeding is not well established. It is important to ensure hemodynamic stability with blood transfusion and to correct any coagulopathy prior to treating the bleeding varices. Endoscopic injection sclerotherapy has been reported to be more effective in the management of active bleeding from rectal varices with less rebleeding rate as compared to endoscopic band ligation. Transjugular intrahepatic portsystemic shunt alone or in combination with embolization is another method used successfully in control of bleeding. Balloon-occluded retrograde transvenous obliteration is an emerging procedure for management of gastric varices that has also been successfully used to treat bleeding rectal varices. Surgical procedures including suture ligation and porto-caval shunts are considered when other methods have failed.

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.

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.

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.

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.

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.

CT evaluation of pararectal varices

PURPOSE

This study was undertaken to determine the prevalence of pararectal varices on CT scan in patients with portal hypertension and to see if dilatation of the inferior mesenteric vein (IMV) or the presence of pararectal varices on CT correlates with rectal varices noted on colonoscopy.

METHOD

We reviewed 83 consecutive CT scans of the abdomen and pelvis performed in patients with portal hypertension. The size and prevalence of pararectal varices were determined. Correlation with colonoscopic and endoscopic reports was performed. The diameter of the IMV was compared in those patients with pararectal varices with that in those patients without, as was the presence of esophageal varices.

RESULTS

Twenty patients (24%) had CT evidence of pararectal varices, ranging from 5 to 11 mm in diameter (mean 7.8 mm). Colonoscopic correlation was available in 30 patients. Of these, 6 of 30 (20%) had pararectal varices on CT and no rectal varices on colonoscopy, 3 of 30 (10%) had pararectal varices on CT and rectal varices on colonoscopy, and 3 of 30 (10%) had no pararectal varices on CT but did have rectal varices on colonoscopy. Endoscopic correlation (available in 48 patients) demonstrated esophageal varices in 88% of patients with rectal or pararectal varices and in 66% of patients without rectal or pararectal varices (p = 0.170). The IMV was significantly larger in patients with pararectal varices (mean diameter 7.5 mm, SD 2.3) as compared with those without (mean diameter 5.8 mm, SD 2.0) (p = 0.014). However, in patients with colonoscopically proven rectal varices, only two of six (33%) had an IMV diameter of > or = 7 mm.

CONCLUSION

Inclusion of the pelvis on CT scans of patients with portal hypertension can yield further information about the presence and extent of pararectal venous collaterals, which may be of particular importance in those patients requiring pelvic surgery. The presence of pararectal varices on CT and the diameter of the IMV do not correlate with the presence of rectal varices on colonoscopy. Decompression of portal hypertension by rectal and pararectal varices does not result in a decreased incidence of esophageal varices.

Endosonographic evaluation of the rectum in children with extrahepatic portal venous obstruction

Rectal endoscopic ultrasonography (REUS) was performed using an Olympus EU-M3 ultrasound fiberscope in 25 children with extrahepatic portal venous obstruction (median age of 8, range 3-16 years) and in eight control subjects (median age of 8, range 6-13). Rectal varices (tortuous or nodular distended veins seen beneath the mucosa) and portal hypertensive rectopathy were diagnosed endoscopically. At rectal endosonography, rectal varices were seen as rounded, oval, or longitudinal echo-free structures in the submucosa. Perirectal veins outside the rectal wall were also seen in REUS. Portal hypertensive rectopathy was endoscopically observed in nine (36%) patients. Rectal varices were detected by endoscopy in nine (36%) and by endosonographic examination in 19 (76%) patients with extrahepatic portal venous obstruction. The number (2, range 0-10) and size (3, range 0-4.5 mm) of submucosal veins seen on endosonography in patients were greater than in controls (0, range 0-1, and 0, range 0-2 mm; p < 0.001 for both). The size of perirectal veins was greater in patients than in controls (3.5, range 3-5 mm versus 2.5, range 2-3 mm; p < 0.001). Communicating veins between the submucosal and perirectal veins were seen in nine (36%) patients. Rectal endoscopic ultrasonography was superior to endoscopy in detecting the presence of rectal varices (76% versus 35%, p < 0.005). Our study suggests that endosonography is useful in detecting changes in the rectal and perirectal vasculature in patients with extrahepatic portal venous obstruction.

Current endosonographic possibilities in the upper gastrointestinal tract

Almost 15 years after its introduction endosonography is an important technique in a wide range of gastrointestinal diseases. Two types of dedicated echoendoscopes are commercially available each with their own advantages. Thinner instruments with higher resolutions, that will go through a normal endoscope are currently in development. With these probes differentiation between T1 and T in situ will be possible in the near future. Characterization of 'submucosal' lesions in the upper gastrointestinal tract is a field in which ES is the most reliable technique for determining the origin of these lesions. Also submucosal vessels are easily visualized and ES is acquiring an important role in the investigation of portal hypertension. ES is the most accurate staging technique for oesophageal and gastric carcinoma as well as for gastric lymphoma. T- and N-staging results are superior to CT scanning, although ES is not very reliable in individual lymph nodes. Therefore a lot of effort is put into obtaining cytological samples from lesions outside the gastrointestinal tract. It is now possible to get cytological proof of mediastinal lymph nodes through ES-guided fine needle aspiration biopsy. It seems that low grade malignant gastric lymphomas show a typical picture on ES, which may help in selecting treatment. The future will bring us higher resolution images and three-dimensional reconstruction is already being investigated. This last technique will probably become a standard preoperative investigation in oesophageal carcinoma before the century is over.