Abstract Rectal variceal bleeding secondary to portal hypertension is a common complication in patients with liver cirrhosis1. There are established guidelines for management of esophageal varies, for rectal varices there are limited guidelines2. This is a case of massive rectal hemorrhage managed with balloon tamponade, which is designed for upper gastrointestinal hemorrhage. This is the case of a 64-year-old male with significant past medical history of hypertension, diabetes mellitus, end stage kidney disease (dialysis dependent), and cirrhosis, who presented with abdominal pain. He had large volume ascites and pleural effusions, and biliary obstruction for which he underwent stent placement. He was scheduled for endoscopic ultrasound and liver biopsy; however, his course was complicated by PEA cardiac arrest, and he was transferred to ICU post-cardiac arrest for further management. Plans for liver biopsy were on hold while patient was in the ICU. He was extubated and doing well when he developed rectal bleeding. CTA of the abdomen and pelvis revealed rectal extravasation of contrast consistent with hemorrhage. Patient underwent emergent colonoscopy that revealed external hemorrhoids, the colon was filled with clots with active bleeding at the level of the rectum. Endo-clot was applied, as well as an endo-clip and hemo-spray. The bleeding appeared controlled. Patient received 2 packed red blood cell transfusions prior to the procedure. He remained hemodynamically stable for 12 hours before he had recurrent rectal bleeding with passage of large clots and went into hemorrhagic shock. Massive transfusion protocol was initiated, and patient was started on vasopressin and norepinephrine. At this time, interventional radiology (IR), gastroenterology, and colorectal surgery, were not offering any procedural intervention. The bleeding persisted, tamponade with a rectal tube was attempted but did not slow the bleeding. Due to persistent bleeding requiring massive transfusion, the decision was made to rectally insert a Blakemore tube to tamponade the bleed. The patients’ hemodynamics improved after placement, and was taken to IR later that day for embolization. He had 13 coils placed in the right and left superior rectal arteries. The patient was discharged from the hospital 10 days later. Balloon tamponade should be considered in cases of acute massive gastrointestinal bleeding. It may be reserved for cases where other management has failed2. This technique provides immediate hemostasis, and these devices are commonly available and easily inserted. Complications may include ischemic necrosis, perforation, or ulceration. It is necessary to avoid over- or prolonged inflation to avoid these complications2. This abstract is funded by: Florida Atlantic University Charles E. Schmidt College of Medicine
Perham et al. (Fri,) studied this question.