Endoscopy 2017; 49(S 01): E136-E137
DOI: 10.1055/s-0043-104521
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic ultrasound-guided hemostasis of rectal varices

Tanima Jana*
Department of Internal Medicine, Division of Gastroenterology, Hepatology & Nutrition, Houston Health Sciences Center, Houston, Texas, USA
,
Tejal Mistry*
Department of Internal Medicine, Division of Gastroenterology, Hepatology & Nutrition, Houston Health Sciences Center, Houston, Texas, USA
,
Shashideep Singhal
Department of Internal Medicine, Division of Gastroenterology, Hepatology & Nutrition, Houston Health Sciences Center, Houston, Texas, USA
› Author Affiliations
Further Information

Publication History

Publication Date:
22 March 2017 (online)

The prevalence of rectal varices in patients with cirrhosis ranges from 38 % to 56 % [1]. While lower gastrointestinal endoscopy can help diagnose rectal varices, endoscopic ultrasound (EUS) may be more accurate in patients with smaller varices [1]. Reports are limited, but techniques for EUS-guided hemostasis of rectal varices include: injection sclerotherapy [2], band ligation [3], embolization with coils [4], and glue injection [4] [5]. Interventional radiology procedures, such as transjugular intrahepatic portosystemic shunting and balloon-occluded retrograde transvenous obliteration, are helpful only in selected patients. Here we describe a unique case of EUS-guided hemostasis of rectal varices using coils and glue.

Our patient was a 54-year-old man with a history of chronic hepatitis C (genotype 1b, treatment-naïve) who presented with a 1-month history of hematochezia. His vital signs were blood pressure of 120/70 mmHg and heart rate of 70 beats per minute. Initial laboratory tests revealed the following results: hemoglobin 9.1 g/dL, platelets 67 000/µL, and he had a MELD score of 11.

Colonoscopy revealed large rectal varices. On EUS, a grape-like bunch of rectal varices was seen, which showed sluggish blood flow on Doppler exam. It was decided to treat the varices with embolization coils and glue. A 22-gauge EUS-guided fine needle aspiration (FNA) needle (EchoTip Ultra; Cook Medical, Limerick, Ireland) and embolization coils (MicroNester; Cook Medical, Bjaeverskov, Denmark) were used.

The EUS-FNA needle was used to puncture the feeder vessel. One 10-mm × 7-cm coil was anchored into the wall of the feeder vessel and deployed into the lumen under sonographic guidance ([Fig. 1]). Another 10-mm × 7-cm embolization coil was similarly deployed in an adjacent feeder vessel. A further medium varix was identified, and an 8-mm × 14-cm embolization coil was deployed, giving a total of three coils deployed in two columns. Endoscopy showed the proximal end of the coil anchored in the rectal mucosa ([Fig. 2]). Under direct endoscopic view with EUS assistance, 0.8 mL of n-butyl-2-cyanoacrylate glue (Covidien SwiftSet; United Kingdom) was injected into the rectal varix at the site of coil deployment. Doppler examination confirmed a reduction in blood flow after coil placement and glue injection ([Video 1]).

Zoom Image
Fig. 1 Endoscopic ultrasound showing deployment of embolization coils (yellow arrow).
Zoom Image
Fig. 2 Endoscopy showing the embolization coils anchored in the rectal mucosa.
Video 1: Endoscopic ultrasound-guided hemostasis of rectal varices with coils and glue.

Quality:

At 4-week follow-up, our patient reported no further rectal bleeding and his hemoglobin was stable. There were no procedural complications.

Endoscopy_UCTN_Code_TTT_1AQ_2AZ

* Joint first authors


 
  • References

  • 1 Al Khalloufi K, Laiyemo AO. Management of rectal varices in portal hypertension. World J Hepatol 2015; 7: 2992-2998
  • 2 Connor EK, Duran-Castro OL, Attam R. Therapy for recurrent bleeding from rectal varices by EUS-guided sclerosis. Gastrointest Endosc 2015; 81: 1280-1281
  • 3 Sharma M, Rai P, Bansal R. EUS-assisted evaluation of rectal varices before banding. Gastroenterol Res Pract 2013; 2013: 619187
  • 4 Weilert F, Shah JN, Marson FP. et al. EUS-guided coil and glue for bleeding rectal varix. Gastrointest Endosc 2012; 76: 915-916
  • 5 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: 1106-1108