Management of internal hemorrhoidal bleeding refractory to endoscopic treatment in a patient with liver cirrhosis

Introduction and Objectives

Hemorrhoidal bleeding associated with portal hypertension is a rare complication. Endoscopic management is the initial treatment recommended. There are no established guidelines in refractory bleeding; we present a patient with hemorrhoidal bleeding refractory to endoscopic treatment.

Clinical case

A 72-year-old woman with decompensated liver cirrhosis and hemorrhoidal disease presented hemorrhoidal bleeding treated with endoscopic band ligation; five days later, rectal bleeding returned. Colonoscopy showed post-ligation ulcers and active bleeding; endoscopic bleeding control with band ligation and sclerotherapy was not achieved (Image 1A-1B). Venography of hemorrhoidal veins and embolization with coils and Histoacryl was performed, achieving bleeding control (Image 1B-C), and hepatic-portal vein gradient was measured (33 mmHg).

Discussion

Symptomatic hemorrhoidal disease in liver cirrhosis has a prevalence of 5%, and it is associated with greater vascular collaterality, coagulopathy and high surgical risk. The treatment options go from endoscopic band ligation, sclerotherapy and arterial or vein embolization, with rebleeding rates between 10-13% in different case series, being the last option of treatment, the portosystemic derivation, which has shown suboptimal results. There are no established guidelines for its management because the evidence of the different therapeutic options is insufficient.

Conclusion

Embolization of hemorrhoidal vessels with refractory bleeding is a good alternative for bleeding control in patients with liver cirrhosis.

Funding

The resources used in this study were from the hospital without any additional financing

Declaration of interest

The authors declare no potential conflicts of interest.

Figure 1. A Retroflection colonoscopy shows post-ligation ulcers with active bleeding. 1.B Venography of superior hemorrhoidal veins with dilatation of left system (white arrow) and contrast leakage at distal rectum (black arrows). 1.C-D. Embolization with coils/Histoacryl, showing absence of distal contrast.