Anorectal varices are the

dilation Dilation (or dilatation) may refer to: Physiology or medicine * Cervical dilation, the widening of the cervix in childbirth, miscarriage etc. * Coronary dilation, or coronary reflex * Dilation and curettage, the opening of the cervix and surgic ...

of collateral submucosal vessels due to backflow in the veins of the

rectum The rectum is the final straight portion of the large intestine in humans and some other mammals, and the Gastrointestinal tract, gut in others. The adult human rectum is about long, and begins at the rectosigmoid junction (the end of the s ...

. Typically this occurs due to

portal hypertension Portal hypertension is abnormally increased portal venous pressure – blood pressure in the portal vein and its branches, that drain from most of the intestine to the liver. Portal hypertension is defined as a hepatic venous pressure gradient gr ...

which shunts venous blood from the

portal system In the circulatory system of animals, 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 are co ...

through the portosystemic anastomosis present at this site into the systemic venous system. This can also occur in the

esophagus The esophagus (American English) or oesophagus (British English; both ), non-technically known also as the food pipe or gullet, is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the ...

, causing

esophageal varices Esophageal varices are extremely 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 tendency to develop ...

, 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 simila ...

. 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. The ...

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 Organ (anatomy), organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of proteins and biochemicals necessary for ...

as part of the

portal venous system In the circulatory system of animals, 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 are co ...

. Blood from the middle and inferior portions of the

is drained via the middle and

inferior rectal vein The lower part of the external hemorrhoidal plexus is drained by the inferior rectal veins (or inferior hemorrhoidal veins) into the internal pudendal vein The internal pudendal veins (internal pudic veins) are a set of veins in the pelvis. They ...

s. In

, venous resistance is increased within the

; when the pressure in the portal venous system increases above that of the

systemic Systemic fundamental to a predominant social, economic, or political practice. This refers to: In medicine In medicine, ''systemic'' means affecting the whole body, or at least multiple organ systems. It is in contrast with ''topical'' or ''loc ...

, 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 Anorectal varices are the dilation of collateral submucosal vessels due to backflow in the veins of the rectum. Typically this occurs due to portal hypertension which shunts venous blood from the portal system through the portosystemic anasto ...

and

haemorrhoids Hemorrhoids (or haemorrhoids), also known as piles, are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term ''he ...

are often used interchangeably, but this is not correct. Haemorrhoids occur due to prolapse of the

rectal venous plexus The rectal venous plexus (or hemorrhoidal plexus) surrounds the rectum, and communicates in front with the vesical venous plexus in the male, and the vaginal venous plexus in the female. A free communication between the portal and systemic venous ...

and are no more common in patients with portal hypertension than those without. Rectal varices, however, are only found in patients with portal hypertension and are common in conditions such as

cirrhosis Cirrhosis, also known as liver cirrhosis or hepatic cirrhosis, and end-stage liver disease, is the impaired liver function caused by the formation of scar tissue known as fibrosis due to damage caused by liver disease. Damage causes tissue repai ...

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 Rectum