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Anorectal varices

Anorectal varices are enlarged, tortuous veins located in the lower rectum and anus.
The pathophysiology of anorectal varices is primarily related to portal hypertension. This increased pressure forces blood to flow through smaller collateral veins, leading to the development of varices in the anorectal region.
The incidence of anorectal varices associated with different pathologies varies from 38% to 95%, with an incidence of up to 89% in patients with portal hypertension.
Disease course
Clinically, patients with anorectal varices may present with symptoms such as rectal bleeding, pain, and discomfort. However, these varices are often asymptomatic until they rupture and bleed.
Prognosis and risk of recurrence
The prognosis of anorectal varices is largely dependent on the severity of the underlying condition causing portal hypertension. Complications can include bleeding, which can be significant in some cases.
Key sources
The following summarized guidelines for the evaluation and management of anorectal varices are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES/AAST 2021).


1.Diagnostic investigations

History and physical examination: consider eliciting a focused medical history and performing a complete physical examination, including a DRE, to rule out other causes of lower gastrointestinal bleeding in patients with suspected bleeding anorectal varices.
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  • Laboratory tests

  • Diagnostic imaging

2.Diagnostic procedures

Lower gastrointestinal endoscopy: consider performing ano-proctoscopy or flexible sigmoidoscopy as first-line diagnostic tool in patients with suspected bleeding anorectal varices.
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3.Medical management

General principles: consider ensuring multidisciplinary management for patients with bleeding anorectal varices, early involving the hepatology specialist team and focusing on optimal control of comorbid conditions.

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  • Resuscitation

  • Beta-blockers

  • Vasoactive agents

  • Antibiotic prophylaxis

4.Therapeutic procedures

Local procedures: consider performing any of the following local procedures in patients with bleeding anorectal varices to arrest bleeding in the first instance if possible:
endoscopic variceal ligation
endoscopic band ligation
EUS-guided glue injection

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  • Angioembolization

  • TIPS

  • Doppler-guided hemorrhoidal artery ligation

5.Surgical interventions

Stapled anopexy: insufficient evidence to recommend for or against stapled anopexy in patients with bleeding anorectal varices and failure of medical treatment, local and radiological procedures.