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Images in clinical medicine. Rectal varices.

A 71-year-old woman with primary biliary cirrhosis had recurrent lower gastrointestinal bleeding requiring transfusions. At colonoscopic examination, large rectal varices were the only apparent source of bleeding (Panel A). A transjugular intrahepatic portosystemic shunt was inserted for portal decompression. The portoatrial pressure gradient subsequently fell from 28 mm Hg to 2 mm Hg. Angiography of the inferior mesenteric venous system (Panel B) revealed a dilated, tortuous inferior mesenteric vein (arrowhead), large rectal varices (straight arrow), and shunting of blood from the portal to the systemic circulation (curved arrow). Flexible sigmoidoscopy performed after portal decompression showed no evidence of residual rectal varices (Panel C). Mild hepatic encephalopathy developed after the insertion of the shunt, and it was easily controlled with lactulose. At follow-up 12 months later, the patient had had no further bleeding or need for transfusions, her overall clinical status was deemed excellent, and the shunt was patent on ultrasonographic evaluation. J. B ARRY O’C ONNOR , M.D. Duke University Medical Center Durham, NC 27710