Gastroenterology clinical image challenge: A 64-year-old woman with a lifelong history of hemorrhoids presented with worsening hematochezia. She described painless passage of large amounts of bright red blood per rectum, but otherwise denied any change in bowel habits or constitutional symptoms. Her last colonoscopy two years prior had only discovered hemorrhoids, which were treated conservatively. On examination, she appeared pale. Proctoscopy revealed the presence of hemorrhoids. Bloods tests only showed anemia (hemoglobin, 7.4 g/dL), with normal electrolytes, liver function and coagulation profile.
Over the course of the next few days, she had multiple episodes of hematochezia. Esophagogastroduodenoscopy revealed no source of bleeding in the upper gastrointestinal tract, such as peptic ulcers or esophageal or gastric varices. Repeat colonoscopy showed multiple colorectal varices and bleeding hemorrhoids. Attempts were made at endoscopic hemostasis with clipping and argon plasma coagulation, as well as surgical suture hemostasis of hemorrhoidal tissue. Unfortunately, the bleeding persisted.
On the sixth day of admission, she had an episode of massive hematochezia associated with hypotension. After resuscitation with fluids and blood products, an urgent computed tomography mesenteric angiogram was performed. This showed several dilated and tortuous extrahepatic portosystemic variceal shunts, engorgement and thrombosis of the tributaries of the mesenteric veins, multiple submucosal varices extending from the descending colon to the anal canal, and mesenteric congestion in the pelvis and surrounding the anal canal. Arterial blush was seen in the distal rectum with pooling of contrast (Figures). She underwent embolization of bleeding branches of the superior rectal artery (Figure).
What is the cause of the refractory hematochezia?
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