Chip Bowman-Zamora, MD, MPH, Richa Bhardwaj, MD, Saikiran Kilaru, MD, James Crismale, MD; Mount Sinai Hospital, New York, NY
Introduction: Rectal varices are portosystemic collaterals that form as a complication of portal hypertension, with an estimated prevalence of up to 56% among patients with cirrhosis. While bleeding occurs in only about 5% of those with rectal varices, the morbidity and mortality of bleeding rectal varices is high. Here we present a case of a stercoral ulcer overlying a rectal varix, leading to massive lower gastrointestinal bleeding (LGIB).
Methods: A 68-year-old male with chronic lower back pain on opioids and decompensated hepatitis C virus cirrhosis complicated by multifocal hepatocellular carcinoma presented with abdominal distention, constipation, and rectal pain. Shortly after admission, he developed hematochezia. Lab work showed a drop in hemoglobin from 9gm/dL to 6gm/dL. CT of the abdomen showed significant stool burden. He underwent an extended colonoscopy preparation. A flexible sigmoidoscopy demonstrated a large nonbleeding polypoid rectal lesion that was superficially ulcerated and partially obstructing the anal canal. Endoscopic ultrasound was subsequently performed to further characterize this lesion. No endosonographically masses were noted. Instead, multiple medium sized varices were seen, one of which had a clean based ulcer without evidence of active bleeding, corresponding to the lesion previously identified on flexible sigmoidoscopy. The following day the patient developed additional episodes of hematochezia, requiring transfusion of packed red blood cells. The rectal varices were then embolized using a combination of coils and sodium tetradecyl sulfate foam via a transhepatic approach. He had no further episodes of rectal bleeding and was discharged home on a bowel regimen. Discussion: Both stercoral ulcers and rectal varices can cause significant LGIB, but there are no prior reports in the literature of both lesions presenting simultaneously. While an actively bleeding stercoral ulcer can typically be managed endoscopically, endoscopic options for the management of rectal varices are limited, particularly in the setting of concomitant rectal pathology. As such, gastroenterologists should consider early consultation with interventional radiologists, particularly in the setting of LGIB presenting with rectal varices with high risk stigmata. In addition, this case highlights the importance of aggressive management of constipation in patients with known rectal varices, particularly in those on chronic opioids.
Flexible Sigmoidoscopy image of stercoral ulcer
EUS image of stercoral ulcer
Disclosures: Chip Bowman-Zamora indicated no relevant financial relationships. Richa Bhardwaj indicated no relevant financial relationships. Saikiran Kilaru indicated no relevant financial relationships. James Crismale indicated no relevant financial relationships.