Anorectal varices

Anorectal varices are the dilation of collateral submucosal vessels due to backflow in the veins of the rectum.^[1] Typically this occurs due to portal hypertension which shunts venous blood from the portal system through the portosystemic anastomosis present at this site into the systemic venous system.^[2]^[3] This can also occur in the oesophagus, causing oesophageal varices, and at the level of the umbilicus, causing caput medusae.^[4] Between 44% and 78% of patients with portal hypertension get anorectal varices.^[3]^[5]

Pathogenesis

Blood from the superior portion of the rectum normally drains into the superior rectal vein and via the inferior mesenteric vein to the liver as part of the portal venous system. Blood from the middle and inferior portions of the rectum is drained via the middle and inferior rectal veins. In portal hypertension, venous resistance is increased within the portal venous system; when the pressure in the portal venous system increases above that of the systemic, blood is shunted through the portosystemic anastomoses. The shunting of blood and consequential increase of pressure through the collateral veins causes the varicosities.

Diagnosis

The terms rectal varices and haemorrhoids are often used interchangeably, but this is not correct.^[6] Haemorrhoids occur due to prolapse of the rectal venous plexus and are no more common in patients with portal hypertension than those without.^[7] Rectal varices, however, are only found in patients with portal hypertension and are common in conditions such as cirrhosis.^[8]

Treatment

Unlike oesophageal varices, rectal varices are less prone to bleeding, are less serious when a bleed does occur, and are easier to treat because of the more accessible location.^[9]

Typically, treatment consists of addressing the underlying portal hypertension. Some treatments include portosystemic shunting, ligation, and under-running suturing.^[5] Insertion of a transjugular intrahepatic portosystemic shunt (TIPS) has been shown to alleviate varices caused by portal hypertension.^[1] Successful treatment of portal hypertension that subsequently reduces anorectal varices provides a confirmation of the initial diagnosis, allowing for a distinction between varices and hemorrhoids, which would not have been alleviated by reduction of portal hypertension.

References

1 2 Katz, JA; Rubin, RA; Cope, C; Holland, G; Brass, CA (Jul 1993). "Recurrent bleeding from anorectal varices: successful treatment with a transjugular intrahepatic portosystemic shunt.". The American journal of gastroenterology. 88 (7): 1104–7. PMID 8317414.
↑ Hunt AH. 'A contribution to the study of portal hypertension. Edinburgh: Livingstone, 1958: 61.
1 2 Chawla, Y; Dilawari, J B (1 March 1991). "Anorectal varices--their frequency in cirrhotic and non-cirrhotic portal hypertension.". Gut. 32 (3): 309–311. doi:10.1136/gut.32.3.309.
↑ Moubarak, Elie; Bouvier, Antoine; Boursier, Jérôme; Lebigot, Jérôme; Ridereau-Zins, Catherine; Thouveny, Francine; Willoteaux, Serge; Aubé, Christophe (15 October 2011). "Portosystemic collateral vessels in liver cirrhosis: a three-dimensional MDCT pictorial review". Abdominal Imaging. doi:10.1007/s00261-011-9811-0.
1 2 Hosking, SW; Smart, HL; Johnson, AG; Triger, DR (1989-02-18). "Anorectal varices, haemorrhoids, and portal hypertension.". Lancet. 1 (8634): 349–52. PMID 2563507. doi:10.1016/s0140-6736(89)91724-8.
↑ McCormack TT BHSJJA. Rectal varices are not piles. Br J Surg. Fev 1984;71(2):163.
↑ Jacobs DM, Bubrick MP, Onstad GP, Hitchcock CR. The relationship of haemorrhoids to portal hypertension. Dis Col Rect 1980:23(8):567-9.
↑ Zuberi FF ZBKMKM. Frequency of rectal varices in patients with cirrhosis. J Coll Physicians Surg Pak. Feb 2004;14(2):94-7.
↑ Johansen K. Bardin J. Orloff MJ. Massive bleeding from hemorrhoidal varices in portal hypertension. JAMA 1980:224 (18): 2084-5.

Diseases of the digestive system (primarily K20–K93, 530–579)

Upper GI tract

Esophagus	Esophagitis Candidal Eosinophilic Herpetiform Rupture Boerhaave syndrome Mallory-Weiss syndrome UES Zenker's diverticulum LES Barrett's esophagus Esophageal motility disorder Nutcracker esophagus Achalasia Diffuse esophageal spasm Gastroesophageal reflux disease (GERD) Laryngopharyngeal reflux (LPR) Esophageal stricture Megaesophagus
Stomach	Gastritis Atrophic Ménétrier's disease Gastroenteritis Peptic (gastric) ulcer Cushing ulcer Dieulafoy's lesion Dyspepsia Pyloric stenosis Achlorhydria Gastroparesis Gastroptosis Portal hypertensive gastropathy Gastric antral vascular ectasia Gastric dumping syndrome Gastric volvulus

Lower GI tract:
Intestinal/
Enteropathy

Small intestine (Duodenum/Jejunum/Ileum)	Enteritis Duodenitis Jejunitis Ileitis Peptic (duodenal) ulcer Curling's ulcer Malabsorption: Coeliac Tropical sprue Blind loop syndrome Small bowel bacterial overgrowth syndrome Whipple's Short bowel syndrome Steatorrhea Milroy disease Bile acid malabsorption
Large intestine (Appendix/Colon)	Appendicitis Colitis Pseudomembranous Ulcerative Ischemic Microscopic Collagenous Lymphocytic Functional colonic disease IBS Intestinal pseudoobstruction / Ogilvie syndrome Megacolon / Toxic megacolon Diverticulitis/Diverticulosis
Large and/or small	Enterocolitis Necrotizing Gastroenterocolitis IBD Crohn's disease Vascular: Abdominal angina Mesenteric ischemia Angiodysplasia Bowel obstruction: Ileus Intussusception Volvulus Fecal impaction Constipation Diarrhea Infectious Intestinal adhesions
Rectum	Proctitis Radiation proctitis Proctalgia fugax Rectal prolapse Anismus
Anal canal	Anal fissure/Anal fistula Anal abscess Anal dysplasia Pruritus ani

GI bleeding/BIS

Accessory

Liver	Hepatitis Viral hepatitis Autoimmune hepatitis Alcoholic hepatitis Cirrhosis PBC Fatty liver NASH Vascular Budd-Chiari syndrome Hepatic veno-occlusive disease Portal hypertension Nutmeg liver Alcoholic liver disease Liver failure Hepatic encephalopathy Acute liver failure Liver abscess Pyogenic Amoebic Hepatorenal syndrome Peliosis hepatis Metabolic disorders Wilson's disease Hemochromatosis
Gallbladder	Cholecystitis Gallstones/Cholecystolithiasis Cholesterolosis Rokitansky-Aschoff sinuses Postcholecystectomy syndrome Porcelain gallbladder
Bile duct/ Other biliary tree	Cholangitis Primary sclerosing cholangitis Secondary sclerosing cholangitis Ascending Cholestasis/Mirizzi's syndrome Biliary fistula Haemobilia Gallstones/Cholelithiasis Common bile duct Choledocholithiasis Biliary dyskinesia Sphincter of Oddi dysfunction
Pancreatic	Pancreatitis Acute Chronic Hereditary Pancreatic abscess Pancreatic pseudocyst Exocrine pancreatic insufficiency Pancreatic fistula

Abdominopelvic

Hernia	Diaphragmatic Congenital Hiatus Inguinal Indirect Direct Umbilical Femoral Obturator Spigelian Lumbar Petit's Grynfeltt-Lesshaft Undefined location Incisional Internal hernia Richter's
Peritoneal	Peritonitis Spontaneous bacterial peritonitis Hemoperitoneum Pneumoperitoneum

Cardiovascular disease (vessels) (I70–I99, 440–456)

Arteries, arterioles
and capillaries

Inflammation

Peripheral artery disease

Arteriosclerosis	Atherosclerosis Foam cell Fatty streak Atheroma Intermittent claudication Critical limb ischemia Monckeberg's arteriosclerosis Arteriolosclerosis Hyaline Hyperplastic Cholesterol LDL Oxycholesterol Trans fat
Stenosis	Carotid artery stenosis Renal artery stenosis
Other	Aortoiliac occlusive disease Degos disease Erythromelalgia Fibromuscular dysplasia Raynaud's phenomenon

Aneurysm / dissection /
pseudoaneurysm

Vascular malformation

Vascular nevus

Veins

Inflammation	Phlebitis
Venous thrombosis / Thrombophlebitis	primarily lower limb Deep vein thrombosis abdomen Hepatic veno-occlusive disease Budd–Chiari syndrome May–Thurner syndrome Portal vein thrombosis Renal vein thrombosis upper limb / torso Mondor's disease Paget–Schroetter disease head Cerebral venous sinus thrombosis Post-thrombotic syndrome
Varicose veins	Gastric varices Portacaval anastomosis Caput medusae Esophageal varices Hemorrhoid Varicocele
Other	Chronic venous insufficiency Chronic cerebrospinal venous insufficiency Superior vena cava syndrome Inferior vena cava syndrome Venous ulcer

Arteries or veins

Blood pressure

Hypertension	Hypertensive heart disease Hypertensive emergency Hypertensive nephropathy Essential hypertension Secondary hypertension Renovascular hypertension Benign hypertension Pulmonary hypertension Systolic hypertension White coat hypertension
Hypotension	Orthostatic hypotension

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