Guideline 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 Guidelines 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. C Laboratory tests: Consider checking vital signs and obtaining Hgb, hematocrit and coagulation to evaluate the severity of bleeding in patients with suspected anorectal varices. C Consider obtaining blood typing and cross-matching in patients with severe anorectal bleeding. C Diagnostic imaging: consider obtaining EUS with/without color Doppler evaluation as a second- line diagnostic tool in patients with bleeding anorectal varices, especially for deep rectal varices or https://web.pathway.md/diseases/reccbBbny3Q8ooGZ3 1/3 6/23/23, 2:38 AM Anorectal varices Pathway when in doubt. C Show 2 more 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. C Show 2 more 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. C Resuscitation: consider administering IV fluids, blood transfusion if necessary, correction of coagulopathy, and optimal medication for portal hypertension in patients with anorectal varices and mild bleeding. C Show 2 more Beta-blockers: Consider administering nonselective -adrenergic blockers for the prevention/prophylaxis of first and/or recurrent variceal bleeding in patients with anorectal varices. C Consider suspending -blockers temporarily in patients with acute bleeding. C Vasoactive agents: consider administering vasoactive drugs such as terlipressin or octreotide to reduce splanchnic blood flow and portal pressure in patients with bleeding anorectal varices. C Antibiotic prophylaxis: administer a short course of prophylactic antibiotics in patients with bleeding anorectal varices. B 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 sclerotherapy endoscopic US-guided glue injection. C Angioembolization: Consider performing embolization via interventional radiological techniques for the short-term control of bleeding in patients with bleeding anorectal varices. C https://web.pathway.md/diseases/reccbBbny3Q8ooGZ3 2/3 6/23/23, 2:38 AM Anorectal varices Pathway Insufficient evidence regarding the superiority of one embolization technique over the others in patients with bleeding anorectal varices. I Transjugular intrahepatic portosystemic shunt: consider performing percutaneous TIPS, if not contraindicated, to decompress the portal venous system and to reduce the risk for rebleeding in patients with bleeding anorectal varices and severe portal hypertension. C Doppler-guided hemorrhoidal artery ligation: insufficient evidence to recommend for or against Doppler-guided hemorrhoidal artery ligation in patients with bleeding anorectal varices and failure of medical treatment, local and radiological procedures. I 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. I References 1. Antonio Tarasconi, Gennaro Perrone, Justin Davies et al. Anorectal emergencies: WSES AAST guidelines. World J Emerg Surg. 2021 Sep 16;16 1 48. Open https://web.pathway.md/diseases/reccbBbny3Q8ooGZ3 3/3