Anorectal varices are a well-known complication of portal hypertension. Guidelines from the WSES and AAST provide key recommendations for the management of bleeding anorectal varices.

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Anorectal varices are discrete, dilated, and submucosal veins, which extend from the proximal to the dentate line and into the rectum. They are a well-known complication of portal hypertension, occurring frequently in individuals with portal pressure above 10 mmHg. Though a frequent occurrence, serious haemorrhage from anorectal varices is rarely reported.

The presence of anorectal bleeding in patients with a history of long-standing or uncontrolled portal hypertension is a major clue to suspect anorectal varices. Guidelines from the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) provide key recommendations for managing bleeding anorectal varices.

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Clinical examination and biochemical investigations in patients with suspected bleeding anorectal varices

In patients with suspected bleeding anorectal varices, a focused medical history should be the first step. To rule out other causes of lower gastrointestinal bleeding, a complete physical examination including a digital rectal examination should be carried out.

It is suggested to check vital signs, determine haemoglobin/hematocrit, and assess coagulation to evaluate the severity of the bleeding. Blood typing and cross-matching should be done in case of severe bleeding.

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Imaging investigations in patients with suspected bleeding anorectal varices

In patients with bleeding anorectal varices, endoscopic ultrasound +/- colour doppler evaluation should be used as a second-line diagnostic tool, especially for deep rectal varices or when in doubt.

Contrast-enhanced CT-scan should be performed in patients with bleeding anorectal varices and failed detection of the bleeding site at endoscopy and endoscopic ultrasound, or in cases when endoscopic ultrasound is not available.

In pregnant patients with bleeding anorectal varices and failed ultrasound detection of bleeding site, MRI angiography should be performed, if available and allowed by the clinical scenario.

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Endoscopy in patients with suspected bleeding anorectal varices

In patients with suspected bleeding anorectal varices, ano-proctoscopy or flexible sigmoidoscopy should be used as the first-line diagnostic tool. In patients presenting with high-risk features or evidence of ongoing bleeding, an urgent colonoscopy (plus upper endoscopy) should be performed within 24 hours of presentation.

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Non-operative management in patients with bleeding anorectal varices

In patients with bleeding anorectal varices, multidisciplinary management is suggested in the early phase itself. The team should involve a hepatology specialist team and focus on optimal control of comorbid conditions. In patients with anorectal varices and mild bleeding, it is suggested to use intravenous fluid replacement, blood transfusion (if necessary), correction of coagulopathy, and optimal medication for portal hypertension.

In patients with severe bleeding, it is recommended to maintain a Hb level of at least > 7 g/dl (4.5 mmol/l) during the resuscitation phase and a mean arterial pressure > 65 mmHg, but avoiding fluid overload. Endorectal placement of a compression tube is suggested as a bridging manoeuvre, to help stabilise the patient or to allow the transfer to a tertiary hospital.

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Pharmacological regimen in patients with bleeding anorectal varices

1. In patients with anorectal varices, it is suggested to use non-selective beta-adrenergic blockers for prevention/prophylaxis of first and/or recurrent variceal bleeding. In case of acute bleeding, beta-blockers should be temporarily suspended.
2. Vasoactive drugs, such as terlipressin or octreotide, can be considered to reduce splanchnic blood flow and portal pressure.
3. A short course of prophylactic antibiotics is recommended.
4. Angiography in patients with bleeding anorectal varices
5. In patients with bleeding anorectal varices and failure of medical treatment and local procedures, a “step-up” approach with radiological and then surgical procedures are suggested.
6. It is suggested to use embolization via interventional radiological techniques for the short-term control of bleeding.
7. In patients with severe portal hypertension, a percutaneous transjugular intrahepatic portosystemic shunt (if not contraindicated) should be used to decompress the portal venous system and reduce the risk of rebleeding.
8. Currently, there are no recommendations regarding the superiority of one embolization technique over the others in case of bleeding anorectal varices.

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Surgery in patients with bleeding anorectal varices

In patients with bleeding anorectal varices and failure of medical treatment, local and radiological procedures, it is suggested to use a “step-up” approach with surgical procedures. The use of “per anal” suture ligation is not suggested.

Currently, no recommendation can be made regarding the role of doppler-guided hemorrhoidal artery ligation and stapled apoplexy in patients with bleeding anorectal varices and failure of medical treatment, and local and radiological procedures.

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The guidelines for the management of anorectal issues by WSES and AAST will be discussed in this series pertaining to different conditions-Click here to read the previous parts-Anorectal abscess: Anorectal abscess: Management guideline updates by WSES and AAST, Managing perineal necrotizing fasciitis: How to manage : WSES/AAST guidelines, Complicated Haemorrhoids: Recommendations from the WSES/AAST Guidelines

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