Symptomatic

Hemorrhoids and Anorectal Varices in Children Portal Hypertension ByN.D.

Heaton,

M. Davenport,

With

and E.R. Howard

London, England 0 There have been few reports of the anorectal problems encountered in children with portal hypertension. We report the incidence of anorectal symptoms in a retrospective study of 189 children treated by injection sclerotherapy for esophageal varices secondary to portal hypertension. Anorectal symptoms, proctoscopic findings and treatment have been recorded in this group. The incidence of symptomatic hemorrhoids and rectal varices was 4.2%. Hemorrhoids are rare in children and the increased incidence can be assumed to be secondary to portal hypertension. Treatment is advised only for symptomatic patients and injection sclerotherapy is satisfactory for the majority. Copyright o 1992 by W.B. Saunders Company INDEX WORDS: hemorrhoids.

Portal

hypertension;

varices,

anorectal;

B

LEEDING complications of esophageal varices secondary to portal hypertension (PHT) are well documented in children and injection sclerotherapy has proved to be an effective treatment.’ There have been only occasional reports of anorectal problems in these young patients, although complications of anorectal bleeding or prolapse have been well documented in adults.2-“ We have analyzed the records of 189 children, who are seen regularly for endoscopic review of esophageal varices secondary to PHT, and have recorded any history of anorectal symptoms such as bleeding or prolapse from hemorrhoids as well as any treatment by injection or banding. Anorectal signs of portal hypertension observed on proctoscopy were also recorded and the results are presented here. MATERIALS

AND METHODS

From January 1975 to May 1991,189 children have been treated by injection sclerotherapy for bleeding esophageal varices secondary to PHT.’ The causes of PHT were extrahepatic portal vein obstruction (EHPVO) in 58 children, biliary atresia in 52, congenital hepatic fibrosis in 18, cystic fibrosis in 16, al-antitrypsin deficiency in 9, and cirrhosis in 36. There was a predominance of male children (5:3) with portal vein obstruction and a predominance of female children (3:2) with intrahepatic disease. Successful obliteration of esophageal varices was achieved in 100% of cases of EHPVO taking a mean of 5.4 injections over an mean of 8 months. The children have been followed regularly at 3- to 12-month intervals and anorectal symptoms were recorded if present. Proctoscopic findings were recorded and included internal hemorrhoids and anorectal varices. RESULTS

Eight patients have presented with anorectal symptoms (4 male, 4 female) (Table 1). Seven had bright JournalofPediatric

Surgery, Vol 27, No 7 (July), 1992: pp 833-835

red rectal bleeding and one patient had partial thickness rectal prolapse. The age range was 3 to 12 years (mean, 6.4 years). The etiology of the PHT was EHPVO in 4 and cirrhosis in 4 (cryptogenic 2, extrahepatic biliary atresia post-portoenterostomy 1, and chronic active hepatitis 1). Seven had been treated by injection sclerotherapy for esophageal varices for between 6 months and 7 years, with a mean of 7.5 injections (range, 3 to 12). Although all the patients had splenomegaly, only one had significant hypersplenism associated with severe thrombocytopenia. Six children had internal anal hemorrhoids, one had anorectal varices, and another child had both. Seven had been treated by injection sclerotherapy of their hemorrhoids. One child was treated on two occasions by banding of hemorrhoids. There have been no episodes of life-threatening haemorrhage. There were no complications from the treatment. DISCUSSION

Bright red rectal bleeding in children with PHT is usually secondary to massive upper gastrointestinal hemorrhage and local anorectal causes have been considered rare.5-7 On occasion, however, anorectal bleeding may be associated with major blood 10~s.~ Hemorrhoids are generally considered to be extremely rare in children and seldom a cause of rectal bleeding.Y Anorectal varices represent collaterals between the superior rectal vein that drains the submucosa of the lower rectum and upper part of the anal canal and the systemic venous drainage at the anus.‘” In contrast, it has been suggested from anatomical, histological, and radiological studieslo that the hemorrhoidal plexuses have no direct communication with the portal venous system. Therefore, the incidence of anorectal varices, but not hemorrhoids, might be expected to be increased in patients with PHT.

From the Department of Surgery, King’s Hill Hospital, London, England. Presented at the 38th Annual International Congress of the British Association of Paediattic Surgeons, Budapest. Hungary, July 24-26, 1991. Address reprint requests to N.D. Heaton, FRCS, Senior Surgical Registrar, Firm III office, Department of Surgery, King’s Hill Hospital, Denmark Hill, London SE5 9RS, England. Copyright o 1992 by W.B. Saunders Company 0022-3468/92/2707-0011$03.00/0 833

a34

HEATON, DAVENPORT, AND HOWARD

Table 1. Patients With Portal Hypertension Esophageal Period of

Age Diagnosis

Sex

Esophageal Bleeding

w

Sclerotherapy

Presenting Wiih Anorectal Bleeding

Varices No. of

Anorectal

Esophageal

Pathology

Esophageal

Variceal

Rectal

Clinical

Injections

Obliteration

Bleeding

Findings

Yes

Hemorrhoids

Injection None

(54

Treatment

PVO

F

3

Yes

2

5

Yes

PVO

M

12

Yes

7

6

Yes

?

Rectal varices

PVO

F

0

Yes

7

9

Yes

Hemorrhoids

Injection x2

PVO

F

4

Yes

3

12

Yes No

Yes

Hemorrhoids

Injection x 5,

Cirrhosis

M

8

No

3

8

Yes

Yes

*Hemorrhoids,

Injection

Cirrhosis

M

6

Yes

0.5

5

No

Yes

Hemorrhoids

Injection x2

CAH

M

5

Yes

0.5

3

Yes

*Hemorrhoids

Injection

EHBA

F

5

No

None

0

No -

Yes

Hemorrhoids

Injection x2

banding x2 rectal varices

Abbreviations: PVO, portal vein obstruction; CAH, chronic active hepatitis; EHSA, extraheptic biliary atresia. *Signifies prominent internal and external hemorrhoidal plexuses.

There are no systematic studies on the incidence of hemorrhoids and anorectal varices in children with PHT, and there continues to be controversy over their incidence in adults. Jacobs et al” and BernsteiS found no increase in the incidence of hemorrhoids in PHT in cirrhotic adults. On the other hand, a recent prospective study of 100 adult cirrhotics demonstrated hemorrhoids in 63% and anorectal varices in 44% of patients.“ Chawla and Dilawari13 reported 72 patients with PHT, only 25 of whom were cirrhotics, and found anorectal varices in 78%. Anorectal varices were significantly more common and tended to be larger in noncirrhotic patients (89% v 56%) and also in those patients presenting with esophageal bleeding. The incidence of hemorrhoids was not recorded and none of 72 patients examined had colonic varices. Rabinowitz et all4 reported rectal varices in 3.6% and hemorrhoids in 25% of 412 cirrhotic patients admitted for transplant assessment. They found that the degree of PHT and disease severity was associated with hemorrhoids, but not rectal varices. The problem with adult patients is knowing whether or not there is an increased incidence of hemorrhoids, because of the difficulty of finding a control population. In our retrospective series of children the incidence of symptomatic rectal varices or hemorrhoids was 4.2%. As hemorrhoids are rare in children9 the relatively high incidence of symptomatic hemorrhoids (3.7%) can be assumed to be secondary to PHT. PHT may result in engorgement and prolapse of the

Table 2. Reported Incidence of Symptomatic Anorectal Varices Symptomatic

Incidence

Patients

1%)

Wilson et alI5

21309

0.7%

Johansen et aI’s

5/110

0.5%

Hosking et aI3

2/100

2%

McMormack et aI17

41112

3.6%

l/l89

0.5%

Investigators

Adults

Children (present study) Heaton et al

anorectal mucosa making it more friable and likely to bleed. We have found injection sclerotherapy or banding satisfactory for the treatment of bleeding from hemorrhoids. The reported incidence of symptomatic anorectal varices in adults with PHT is low, ranging from 0.5% Hosking et al4 and Chawla to 3.6% (Table 2) .3,15-17 and Dilwari13 have suggested that when compared with hemorrhoids, anorectal varices represent a later stage in the development of PHT. The incidence of symptomatic anorectal varices in these pediatric patients was 0.5%. The treatment of bleeding anorectal varices has included injection sclerotherapy, banding, cryosurgery, underrunning of varices, hemorrhoidectomy, embolization, and portosystemic shunt.3s15,18 Direct suture may be needed occasionally for the control bleeding from anorectal varices,?l’ but we have no experience of this in children. The incidence of symptomatic anorectal problems in children with PHT from our retrospective study is approximately 4.2%. (Massive or recurrent bleeding is rare.)

REFERENCES 1. Howard ER, Stringer MD, Mowat AP: Assessment of injection sclerotherapy in the management of 152 chiidren with oesophageal varices. Br J Surg 75:404-408, 1988 2. Hamlyn AN, Lunzor MR, Morris JS, et al: Portal hypertension withvarices in unusual sites. Lancet 2:1531-1534,1974 3. Hosking SW, Johnson AC: Bleeding anorectal varices-A misunderstood condition. Surgery K&70-73,1988

4. Hosking SW, Smart HL, Johnson AC, et al: Anorectal varices, haemorrhoids and portal hypertension. Lancet 1:349-352, 1989 5. Alvarez F, Bernard 0, Brunelle F, et al: Portal obstruction in children. I. Clinical investigation and hemorrhage risk. J Pediatr 103:696-702,1983 6. Alvarez F, Bernard 0, Brunelle F, et al: Portal obstruction in

ANORECTAL

VARICES IN CHILDREN

children. II. Results of surgical portosystemic shumts. J Pediatr 103:703-707,1983 7. Pinkerton JA, Holcomb GW, Foster JH: Portal hypertension in childhood. Ann Surg 175:870-886,1972 8. Grauer SE, Schwartz SI: Extrahepatic portal hypertension: A retrospective analysis. Arm Surg 189:566-574,1979 9. Ravitch MM, Welch KJ, Benson CD, et al (eds): Pediatric Surgery (ed 3). Chicago, IL, Year Book, 1984, p 1079 10. Thomson WHF: The nature of haemorrhoids. Br J Surg 62:542-552,1975 11. Jacobs DM, Bubrick MP, Onstad GR, et al: The relationship of hemorrhoids to portal hypertension. Dis Colon Rectum 23:567569,198O 12. Bernstein WC: What are hemorrhoids and what is their relationship to the portal venous system. Dis Colon Rectum 26:829-834, 1983 13. Chawla Y, Dilawari JB: Anorectal varices-Their frequency

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in cirrhotic and non-cirrhotic portal hypertension. Gut 32:309-311. 1991 14. Rabinowitz M, Schade RR, Dindzans VJ, et al: Colonic disease in cirrhosis. An endoscopic evaluation in 412 patients. Gastroenterology 99:195-199,199O 15. Wilson SE, Stone RT, Christie JP, et al: Massive lower gastrointestinal bleeding from intestinal varices. Arch Surg 114: 1158-1161,1979 16. Johansen K, Bardin J, Orloff MJ: Massive bleeding from hemorrhoidal varices in portal hypertension. JAMA 244:20842085,198O 17. McCormack TT, Bailey HR, Simms JM. et al: Rectal varices are not piles. Br J Surg 71:163,1984 18. Weinshel E, Chen W, Falkenstein DB, et al: Hemorrhoids or rectal varices: Defining the cause of massive rectal hemorrhage in patients with portal hypertension. Gastroenterology 90~744-747, 1986

Symptomatic hemorrhoids and anorectal varices in children with portal hypertension.

There have been few reports of the anorectal problems encountered in children with portal hypertension. We report the incidence of anorectal symptoms ...
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