Anorectal varices are collateral submucosal blood vessels dilated by backflow in the veins of the

rectum The rectum (: rectums or recta) is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. Before expulsion through the anus or cloaca, the rectum stores the feces temporarily. The adult ...

. Typically this occurs due to

portal hypertension Portal hypertension is defined as increased portal venous pressure, with a hepatic venous pressure gradient greater than 5 mmHg. Normal portal pressure is 1–4 mmHg; clinically insignificant portal hypertension is present at portal pressures 5� ...

which shunts venous blood from the portal system through the portosystemic anastomosis present at this site into the systemic venous system. This can also occur in the

esophagus The esophagus (American English), oesophagus (British English), or œsophagus (Œ, archaic spelling) (American and British English spelling differences#ae and oe, see spelling difference) all ; : ((o)e)(œ)sophagi or ((o)e)(œ)sophaguses), c ...

, causing

esophageal varices Esophageal varices are extremely Vasodilation, dilated sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis. People with esophageal varices have a strong tendenc ...

, and at the level of the umbilicus, causing

caput medusae Caput medusae is the appearance of distended and engorged superficial epigastric veins, which are seen radiating from the umbilicus across the abdomen. The name ''caput medusae'' (Latin for "head of Medusa") originates from the apparent simil ...

. Between 44% and 78% of patients with portal hypertension get anorectal varices.

Signs and symptoms

Pathogenesis

Blood from the superior portion of the

normally drains into the

superior rectal vein The inferior mesenteric vein begins in the rectum as the superior rectal vein (superior hemorrhoidal vein), which has its origin in the hemorrhoidal plexus, and through this plexus communicates with the middle and inferior hemorrhoidal veins. Th ...

and via the

inferior mesenteric vein In human anatomy, the inferior mesenteric vein (IMV) is a blood vessel that drains blood from the large intestine. It usually terminates when reaching the splenic vein, which goes on to form the portal vein with the superior mesenteric vein (SMV) ...

to the

liver The liver is a major metabolic organ (anatomy), organ exclusively found in vertebrates, which performs many essential biological Function (biology), functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of var ...

as part of the

portal venous system In the circulatory system of vertebrates, a portal venous system occurs when a capillary bed pools into another capillary bed through veins, without first going through the heart. Both capillary beds and the blood vessels that connect them ar ...

. Blood from the middle and inferior portions of the

is drained via the

middle Middle or The Middle may refer to: * Centre (geometry), the point equally distant from the outer limits. Places * Middle (sheading), a subdivision of the Isle of Man * Middle Bay (disambiguation) * Middle Brook (disambiguation) * Middle Creek ...

and inferior rectal veins. In

, venous resistance is increased within the

; 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 A neuroeffector junction is a site where a motor neuron releases a neurotransmitter to affect a target—non-neuronal—cell. This junction functions like a synapse. However, unlike most neurons, somatic efferent motor neurons innervate skeletal m ...

Diagnosis

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

cirrhosis Cirrhosis, also known as liver cirrhosis or hepatic cirrhosis, chronic liver failure or chronic hepatic failure and end-stage liver disease, is a chronic condition of the liver in which the normal functioning tissue, or parenchyma, is replaced ...

Treatment

Unlike esophageal 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. However, in some cases, rectal varices can result in severe bleeding. Weinshel, E., Chen, W., Falkenstein, D. B., Kessler, R., & Raicht, R. F. (1986, March). Hemorrhoids or Rectal Varices: Defining the Cause of Massive Rectal Hemorrhage in Patients With Portal Hypertension. GASTROENTEROLOGY 1986;90:744-. https://www.gastrojournal.org/article/0016-5085(86)91132-7/pdf Archived: https://web.archive.org/web/20210617070007/https://www.gastrojournal.org/article/0016-5085%2886%2991132-7/pdf Typically, treatment consists of addressing the underlying portal hypertension. Some treatments include portosystemic shunting, ligation, and under-running suturing. Insertion of a

transjugular intrahepatic portosystemic shunt Transjugular intrahepatic portosystemic shunt (TIPS or TIPSS) is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein. It is used to treat portal hypertension (which is ...

(TIPS) has been shown to alleviate varices caused by portal hypertension. 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

External links

{{Vascular diseases Diseases of veins, lymphatic vessels and lymph nodes Digestive diseases Colorectal surgery Rectal diseases Anal diseases