rectal varices are not an uncommon manifestation in cirrhosis with portal hypertension . however , serious bleeding from rectal varices is uncommon . because of its rarity ,
several authors have reported the utility of transjugular intrahepatic portosystemic shunt ( tips ) placement to control such bleeding when local therapy , such as endoscopic sclerotherapy or banding , fails [ 2 , 3 , 4 , 5 ] .
however , we experienced a case of massive bleeding from large rectal varices that could not be controlled by tips placement , despite normalization of the portosystemic pressure gradient . furthermore , we observed rapid decompensation of the cirrhosis that led to severe encephalopathy and death after the tips placement .
we report this case to highlight and discuss potential pitfalls of tips placement when using this technique to treat rectal variceal bleeding .
a 59-year - old man with a history of alcoholic cirrhosis was hospitalized at an outside facility for massive hematochezia and fainting .
he underwent upper endoscopy and tagged red blood cell scan , both of which were negative for active bleeding .
a computed tomography of the abdomen was performed and did not reveal the source of the gastrointestinal bleeding ; a nodular liver with splenomegaly consistent with liver cirrhosis was seen , and a markedly dilated inferior mesenteric vein was also noted . during his 5-day hospitalization , he had approximately 1015 bloody bowel movements and received a total of 6 units of packed red blood cells and 2 units of fresh frozen plasma .
the patient was then transferred to our institution for further management of his persistent hematochezia .
his admission laboratory tests showed a hemoglobin level of 8.3 g / dl , a serum ammonia level of 45 g / dl , a total bilirubin level of 2.8 mg / dl and a model for end - stage liver disease ( meld ) score of 18 .
however , he had another episode of massive hematochezia on the following day , with a decrease in hemoglobin level to 5.0 g / dl . therefore , the decision was made to proceed with emergent tips placement .
a tips was successfully created with a 10  90 mm viatorr stent - graft ( gore & associates , flagstaff , ariz .
this resulted in a decrease in the portosystemic pressure gradient from 12 to 6 mm hg .
after the tips placement , brisk hepatopetal flow through the tips was seen on the portogram . despite the successful normalization of the portosystemic pressure gradient , he had another episode of massive bleeding on the following day .
an angiogram of the superior rectal vein was performed , which showed tortuous large rectal varices with brisk hepatofugal flow ( fig .
2 ) . flow into the internal iliac vein branches was observed , confirming portosystemic shunting .
embolization of the rectal varices was then performed , which necessitated multiple coils , 1 ml of n - butyl cyanoacrylate glue , 5,000 units of thrombin and several sheets of gelfoam ( fig .
3 ) . after the procedure , the patient did not have any further bleeding episodes , and the serial hemoglobin levels remained stable .
the remaining hospital course was significant for rapid decompensation of cirrhosis , with an increase in the total bilirubin level to 8.7 mg / dl , the ammonia level to 121 g / dl and the meld score to 28 .
he developed acute hypoxic respiratory failure secondary to multiple causes , including progressive liver failure .
this case highlights two potential pitfalls of tips placement when using this technique in the treatment of rectal variceal bleeding .
first , tipss may not be always successful in controlling serious bleeding from rectal varices , despite optimal portosystemic pressure reduction .
we observed rebleeding after the tips placement despite a 50% reduction in the pressure gradient , with a final pressure gradient of 6 mm hg .
some authors have also reported that a tips failed to control bleeding from rectal varices [ 6 , 7 ] .
recurrent bleeding from rectal varices after tips placement may be related to the large size of the varices .
rectal varices , unlike esophageal varices , are true veins and are likely to have larger diameters . according to laplace 's equation ,
the tension in the varix wall is proportional to the radius of the vessel for any given transmural pressure .
, it is recommended to decrease the portosystemic pressure gradient to < 12 mm hg in esophageal variceal bleeding .
however , this targeted pressure gradient may not be adequate for controlling bleeding from rectal varices .
some authors advocate embolization of the rectal varices at the time of tips placement , even if normalization of portal hypertension is achieved [ 7 , 10 ] . given the successful control of bleeding following embolization in our case , concomitant variceal embolization at the time of tips placement may be necessary to control massive bleeding , especially when the rectal varices are large .
second , tipss can be associated with life - threatening complications that can possibly lead to early mortality .
since the first application of a tips in the treatment of recurrent bleeding from anorectal varices in 1993 , a tips alone or a tips combined with variceal embolization has been reported to be useful in controlling such bleeding without significant morbidity or mortality [ 2 , 3 , 4 , 5 , 10 ] .
however , tipss are inherently associated with risks of procedure - related complications , hepatic encephalopathy and progressive liver failure .
godil and mccracken   reported a case of rapid liver function decompensation and encephalopathy following tips placement in a 73-year - old woman with rectal variceal bleeding .
although no recurrent bleeding was seen , the patient died 4 weeks after the tips procedure . according to the american association for the study of liver diseases practice guidelines , tips is recommended only in the absence of other options for patients with 30-day predicted mortality ( meld > 1518 or serum bilirubin > 4.0 mg / dl ) . although emergent tips placement can be the last resort to control massive bleeding from rectal varices , even in high - risk patients it must be used cautiously because it can lead to life - threatening complications , as seen in our case . despite its minimally invasive nature , tips placement has been associated with a 30-day mortality rate as high as 36% when it is used to control acute gastroesophageal variceal bleeding .
one alternative to tips placement in high - risk patients may be the percutaneous embolization of rectal varices via a transhepatic approach .
although reports on the use of this technique for bleeding rectal varices are limited , it could be useful in controlling an initial acute bleeding and in stabilizing a patient without affecting liver function .
however , collaterals can redevelop after embolization , and recurrent bleeding requiring repeated intervention has been reported .
some authors have reported several cases of obliteration of bleeding large rectal varices with the use of balloon - occluded antegrade transvenous sclerotherapy with or without coil embolization [ 14 , 15 ] . in this technique , a sclerosing agent , such as ethanolamine oleate ,
was injected into the varices while the superior rectal vein was occluded using a balloon catheter .
further research is needed to determine its efficacy . in conclusion , although tipss have been reported to be useful in controlling bleeding from rectal varices , there are potential pitfalls in using this technique to treat rectal variceal bleeding .
a tips may not always be successful in controlling massive bleeding from large rectal varices even after normalization of portal hypertension , and concomitant variceal embolization may be necessary . furthermore , tipss can be associated with life - threatening complications that may lead to early mortality .
 in patients with portal hypertension , bleeding from rectal varices is rare . 
 however , it can be life - threatening . 
 we report a case of massive bleeding from large rectal varices in a 59-year - old man with alcoholic cirrhosis . 
 emergent transjugular intrahepatic portosystemic shunt ( tips ) placement was performed following failed local endoscopic therapy . despite normalization of the portosystemic pressure gradient , the patient had another episode of massive bleeding on the following day . 
 embolization of the rectal varices via tips successfully stopped the bleeding . 
 after the procedure , rapid decompensation of the cirrhosis led to severe encephalopathy , and death was observed . 
 although tipss have been reported to be useful in controlling bleeding from rectal varices , our case illustrates the potential pitfalls in using this technique in the treatment of rectal variceal bleeding . 
 tipss may not be always successful in controlling massive bleeding from large rectal varices , even after normalization of portal hypertension . 
 tipss can also be associated with life - threatening complications that may lead to early mortality . 
Introduction
Case Presentation
Discussion