Rectal arterio-portal fistula: An unusual cause of persistent bleeding per rectum following a proximal spleno-renal shunt

Combination of Percutaneous Transhepatic Balloon-Assisted Transjugular Intrahepatic Collateral Caval Shunt and Embolization for Successful Hemostasis of Lower Gastrointestinal Bleeding Associated With Extremely Enlarged Anorectal Varicose Veins

Ectopic varices may frequently occur in the rectum in the context of portal hypertension. Although rectal variceal bleeding is not a frequent bleeding situation, it can be life-threatening unless diagnosed and treated immediately. However, there is no specific treatment strategy established so far. We report a case of a man with extrahepatic portal hypertension and severe hematochezia due to rectal variceal bleeding. The patient was diagnosed in the past with portal vein thrombosis, in the context of myelodysplastic syndrome/myeloproliferative neoplasm overlap syndrome, with ectopic varices in the small intestine, colon, rectum and anal canal, peritoneum and perisplenic veins, treated with mesorenal shunt placement and an oral beta-blocker. After the initial stabilization with fluid replacement and red blood cell transfusion, he underwent endoscopic injection sclerotherapy, with no effect on bleeding episodes, while the large size of the varices precluded the option of endoscopic band ligation. Due to the presence of large collateral veins next to the inferior vena cava, the patient underwent combination therapy with Percutaneous Transhepatic Balloon-Assisted Transjugular Intrahepatic Collateral Caval shunt placement, to decompress portal pressure, followed by angiographic embolization of the feeding vessels resulting in successful hemostasis. Hematochezia ceased, hemoglobin was stabilized and the patient was safely discharged from the hospital. Controlling and treating rectal varices can be a challenging task indicating the need of a multidisciplinary approach. In the absence of well-established treatment guidelines for rectal varices, we highly recommend treatment of refractory ectopic variceal bleeding, non-responsive to endoscopic treatments, with portocaval shunt placement in combination with embolization.

Unusual Presentation of Anal Pain and Tenesmus from Rectal Arteriovenous Malformation Successfully Treated with Ethanol Sclerotherapy

Gastrointestinal arteriovenous malformation (AVM) is reported as one of the possible causes of intestinal bleeding, and its occurrence in the rectum is rare. We report the case of a rectal AVM patient who experienced uncommon symptoms of anal pain and tenesmus and was treated successfully with percutaneous transarterial ethanol sclerotherapy. The patient underwent routine colonoscopy with biopsy at the time of visit; however, an accurate diagnosis was difficult. Subsequent contrast-enhanced computed tomography (CT) and angiography revealed a rectal AVM emerging from the distal inferior mesenteric artery with engorged superior rectal veins. The feeding artery was catheterized, and concurrent transarterial sclerotherapy with 80% ethanol was performed. There was no major complication related to the procedure. Disappearance of AVM nidus and improvement of associated venous congestion were shown by follow-up CT. There was no recurrence of symptoms after 10 months of clinical observation. Transarterial ethanol sclerotherapy is safe and effective in treating rectal AVM and can be considered as one of the nonsurgical treatment options.