Colon Miscellaneous Atlas of Gastrointestinal Video Endoscopy
rectal varices

Video Endoscopic Sequence 1 of 14.

Endoscopic band ligation in management of rectal varices in patient with liver cirrhosis and portal hypertension.

This is the case of a 66 year-old lady, with cirrhosis, and rectal varices treated with endoscopic band ligation with excellent results.

The patient had had three previous episodes of severe hematochezia and also several episodes of bled because of esophageal varices that has been ligated.

In one session multiple rectal varices were ligated and a congested internal hemorrhoid with the same banding apparatus through the endoscope.

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Endoscopic band ligation in management of rectal varices in patient with liver cirrhosis and portal hypertensio

 

 

 

Endoscopic band ligation in management of rectal varices

Video Endoscopic Sequence 2 of 14.

Esophagogastric varices are considered to be the most common complication in patients with portal hypertension, while ectopic varices, that is, those outside of the esophagogastric region, are less common.

Rectal varices represent portal systemic collaterals that are manifested as discrete dilated submucosal veins and constitute a pathway for portal venous flow between the superior rectal veins of the inferior mesenteric system and the middle inferior rectal veins of the iliac system.

rectal varices

Video Endoscopic Sequence 3 of 14.

Rectal varices are an infrequent but potentially serious cause of hematochezia. Massive bleeding from rectal varices occurs rarely, with a frequency ranging from 0.5% to 3.6%.

Endoscopy is the principal method for diagnosis of rectal varices. Endoscopic ultrasonography (EUS) can detect the presence and number of rectal varices better than endoscopy.

EUS permits identification of deep rectal varices in a large proportion of patients without detectable varices on rectoscopy.

Rectal varices are considered to occur infrequently, however, several articles have reported that they occur with high frequency in patients with hepatic abnormalities.

 

 

 

rectal varices

Video Endoscopic Sequence 4 of 14.

Endoscopy is the principal method for the diagnosis of rectal varices; it is a useful modality for diagnosing and observing rectal varices of a certain size and extent, and has a very sensitive predictive value for variceal hemorrhage.

rectal varices

Video Endoscopic Sequence 5 of 14.

The incidence of ectopic varices in the rectum is likely to increase with improvements in the treatment and survival of patients with portal hypertension.

If a patient with portal hypertension suffers massive lower gastrointestinal hemorrhage, it is important to perform a detailed endoscopic examination, as there is a possibility of rectal varices.

Although a standard therapy for rectal varices has not been established.

Rectal Varices

Video Endoscopic Sequence 6 of 14.

Rectal Varices and internal hemorrhoids seen at retroflexed maneuver

Rectal variceal bleeding is rarely encountered, but can be massive and life-threatening

Rectal varices endoscopic variceal ligation

Video Endoscopic Sequence 7 of 14.

Rectal varices that was successfully treated with endoscopic variceal ligation alone.

Endoscopic variceal ligation is minimally invasive, safe, effective, simple and reliable.

Endoscopic variceal ligation is promising as a possible first line of therapy for rectal varices.

rectal varices.

Video Endoscopic Sequence 8 of 14.

Although endoscopic injection sclerotherapy and endoscopic band ligation for esophageal varices are well-established therapies, there is no standard treatment for rectal varices.

rectal varices.

Video Endoscopic Sequence 9 of 14.

In patients with cirrhosis, portal hypertension can be complicated by bleeding rectal varices.

Treatment of bleeding rectal varices is not well established because clinical therapeutic trials are scarce in the literature and there are only a few case reports. In most cases, first line treatment is endoscopic (band ligation or sclerotherapy) and in case of failure or rebleeding, portosystemic shunts are the second line treatment.

The indication of endoscopic treatment is not always easy in patients with cirrhosis and impaired liver function as well as major hemostatic problems.

Ligation of Rectal Varices

Video Endoscopic Sequence 10 of 14.

Ligation of Rectal Varices

Ligation of Rectal Varices

Video Endoscopic Sequence 11 of 14.

Multiple varices were ligated in one session

Ligation of Rectal Varices

Video Endoscopic Sequence 12 of 14.

One congested internal hemorrhoid were ligated with the same band apparatus.

Hemorrhoids are vascular cushions resulting from arteriolar venous communications in the hemorrhoidal plexus, with no direct communication with any of the major branches of the portal venous system being demonstrated.

Ligation of Rectal Varices

Video Endoscopic Sequence 13 of 14.

Final status of the ligation of rectal varices see the video clip.

Ligation of Rectal Varices

Video Endoscopic Sequence 14 of 14.

Final status of the ligation of rectal varices

Hemorrhage from rectal varices should be kept in mind in patients with portal hypertension presenting with lower gastrointestinal bleeding.

Diffuse Colonic Varices

Video Endoscopic Sequence 1 of 4.

Diffuse Colonic Varices

VARICES OF THE COLON apparently is an exceedingly rare condition.

A 42 year-old male, physician internist, diabetic with morbid obesity, present with rectal bleeding with dark red blood, nine months previous underwent an upper endoscopy due to melena, found reflux esophagitis with a small focus of bleeding but no esophageal varices at colonoscopy a small polyp of the sigmoid was found therefore underwent polypectomy, total protein in serum was low and liver function tests was abnormal.

6 years later, iniciates with upper GI bleeding manifesting with hematemesis and melena an upper endoscopy displays esophageal varices, four varices were ligated, one of which was ulcerated at the gastroesophageal junction.

Since the original description of colonic varices (CV) in 1954, fewer than 100 cases have been reported in the literature. More than 75% of these cases have been due to portal hypertension.

Reported causes include cirrhosis, biliary atresia, biliary sclerosis, congestive heart failure, superior mesenteric vein thrombosis, and inferior mesenteric vein thrombosis. A smaller number are of idiopathic origin.

 

 

 

Diffuse Colonic Varices

Video Endoscopic Sequence 2 of 4.

The entire colon had prominent veins to the cecum

Diagnosis of idiopathic colonic varices is most accurately achieved by mesenteric angiography.

Etiology and natural history of ectopic varices Ectopic varices are defined as large portosystemic venous collaterals occurring anywhere in the abdomen except for the the cardiaesophageal region. These varices account for 1-5% of all variceal bleeding.

The most common location for ectopic varices are the stomach, duodenum, remainder of small bowel, and colon. Rarely, these varices can be noted in the peritoneum, and biliary system.

Ectopic varices has been recognized to occur more frequently following sclerotherapy of esophageal varices and surgical anastamosis sites in patients with portal hypertension.

Colonic varices are surprisingly uncommon in patients with portal hypertension in whom varicosities often develop in the distal esophagus and cardia of the stomach.

 

Diffuse Colonic Varices

Video Endoscopic Sequence 3 of 4.

Retroflexed image in the sigmoid colon shows some varices

The term ‘‘ectopic varices’’ is sometimes reserved for abnormally dilated veins associated with gastrointestinal mucosa and, therefore, with the potential for gastrointestinal hemorrhage.

However, the term has also been used loosely to describe portosystemic collateral veins in the abdominal wall and retroperitoneum.

The distinction between ‘‘ectopic varices’’ and collaterals that are commonly found on the abdominal wall and retroperitoneum of patients with portal hypertension is one of semantics.

Thus, ectopic varices may be best defined as large portosystemic venous collaterals occurring anywhere in the abdomen except in the cardioesophageal region.

Diffuse Colonic Varices

Video Endoscopic Sequence 4 of 4.

Prominent vessels in the ascending colon.

Ectopic varices are an unusual cause of gastrointestinal hemorrhage The clinician caring for patients with gastrointestinal bleeding must be aware of this entity, because diagnosis and management of ectopic varices differ from that of esophagogastric varices.

Furthermore, the prognosis from bleeding ectopic varices may be poor with one study quoting 40% mortality at initial bleed from duodenal varices.

It is important to differentiate anal varices from hemorrhoids: Anal varices collapse with digital pressure, whereas hemorrhoids do not.

In patients with portal hypertension caused by obstruction of the portal or splenic veins, duodenal varices are more prevalent than in patients with intrahepatic portal hypertension. The prevalence is higher if angiography is used.

Rectal Varix

Video Endoscopic Sequence 1 of 2.

Rectal Varix

In a routine colonoscopy displays varices of the rectum which was an incidental finding.

This a 73 year-old female, suffer from liver cirrhosis and portal hypertension, who previously we had liagated in three sessions her esophageal varices, which were eradicated, subsequently suffered another episode of upper gi bleeding due to an ulcer of the duodenal bulb of the the anterior wall. Therapeutic endoscopy was carried out with infiltrations of absolute alcohol.

Paciente femenino de 73 años, conocida por adolecer de cirrosis hepática e hipertensión portal, a quien le habíamos ligado en tres veces sus várices del esófago, las cuales fueron erradicadas, posteriormente a pesar que le habíamos prescrito usar permanente inhibidores de la bomba, ella los había abandonado y posteriormente sufre de un episodio de sangrado del tubo digestivo superior debido a una úlcera de la pared anterior del bulbo duodenal, a la cual le practicamos terapia hemostática con alcohol absoluto.

Varios videos de este caso están aquí en este atlas. tanto el sangrado como las ligaduras de sus várices.

En una colonoscopia de rutina le encontramos várices del recto las cuales fue un hallazgo incidental.

 

Rectal Varix.

Video Endoscopic Sequence 2 of 2.

Rectal Varix

These varices were found in a routine colonoscopy, which was an incidental finding.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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