Colonic Ischemia and Necrosis Following Hemorrhoid Embolization: A Brief Report

Hemorrhoidal disease affects approximately 10 million Americans and can be detrimental to a patient’s quality of life. Hemorrhoids are vascular cushions composed of connective tissue and arteriovenous communications within the anal canal. Their development is attributed to the dilation and distortion of vascular channels, leading to dysregulated vascular tone and hyperplasia. Internal hemorrhoids are prone to prolapse due to the loss of connective tissue support, increasing the risk of trauma and rectal bleeding.

Management of hemorrhoidal disease falls into 3 distinct categories: medical, office-based treatment, and surgical intervention. First-line treatment includes dietary modifications, such as increased fiber and fluid intake, which have been shown to reduce the risk of persistent symptoms by 53% and bleeding by 50%. Office-based procedures, including rubber band ligation, sclerotherapy, and infrared coagulation, are commonly utilized for grade I-III internal hemorrhoids, with rubber band ligation demonstrating the highest long-term success rate of approximately 90%, followed by sclerotherapy (75%-90%) and infrared coagulation. Surgical intervention is reserved for patients with grade III or IV hemorrhoids or those with persistent symptoms, with only 5%-10% of affected individuals requiring operative management.

With advancements in interventional radiology, embolization has emerged as a novel, minimally invasive approach for hemorrhoid management. The embolization technique, first described in 2014, involves arterial occlusion via coil placement in the branches of the superior rectal artery. By occluding terminal hemorrhoidal arterial branches, embolization aims to reduce anorectal trauma while minimizing the morbidity associated with traditional surgical interventions.

A 64-year-old woman with a history of hemorrhoidal disease and refractory rectal bleeding underwent hemorrhoid embolization via right femoral artery access at an outpatient facility. That evening, she developed severe abdominal pain, coffee-ground emesis, and hypotension. Upon presentation to the emergency department, she was hypotensive and tachycardic, prompting transfusion of 2 units of packed red blood cells due to concern for retroperitoneal hemorrhage. She was also hypoxic with suspicion for pulmonary embolism and received a short period of anticoagulation. Cross-sectional imaging did not reveal concern for pulmonary embolism or retroperitoneal hemorrhage but was notable for colonic mucosal thickening with concern for pneumatosis and free air. She was emergently transferred to a tertiary care center for further management.

On arrival, her abdominal pain had worsened, and she developed escalating vasopressor requirements. She was taken emergently to the operating room for an exploratory laparotomy, which revealed feculent peritonitis. Upon evacuation, the sigmoid colon was noted to be frankly necrotic with a large perforation at the rectosigmoid junction. The descending colon was mobilized and divided, but ischemic changes extended to the peritoneal reflection. A rigid sigmoidoscopy demonstrated mucosal ischemia 8 cm from the anal verge, requiring division of the rectum. A 19F Jackson-Pratt drain was placed at the mesenteric base, and a temporary abdominal closure was performed. Two days later, she returned to the operating room for additional resection of the proximal colon and replacement of the temporary abdominal dressing. Definitive surgical intervention was performed the subsequent day requiring additional resection of the proximal and distal margins due to further ischemia with creation of end transverse colostomy. Her post-operative course was complicated by a worsening pleural effusion requiring pigtail catheter placement, urinary retention, and prolonged ileus. She was ultimately discharged to a rehabilitation facility on post-operative day 25.

Hemorrhoid embolization has emerged as a promising minimally invasive alternative for patients with symptomatic hemorrhoidal disease, particularly those with refractory bleeding. Studies have demonstrated favorable efficacy outcomes, with significant reductions in bleeding and symptom burden post-procedure. Gregorio et al conducted a study on 80 patients undergoing embolization, reporting a 100% technical success rate and a 68.7% clinical success rate, defined as the absence of bleeding at 12 months. Importantly, no major complications were reported, reinforcing the potential for this technique as a safe and effective intervention. ¹ Similarly, Nguyenhuy et al performed a systematic review and meta-analysis of 381 patients, finding a significant improvement in bleeding, pain, and quality of life following embolization. This large-scale analysis further supported the procedure’s efficacy and noted an absence of major complications. ²

While generally regarded as safe, hemorrhoid embolization is not without risks. One of the primary concerns is ischemic injury, as embolization targets arterial supply to the rectal venous plexus. De Oliveira et al investigated the feasibility of embolizing both the superior rectal artery (SRA) and middle rectal artery (MRA) in 10 patients. Although the procedure was largely successful, 1 patient developed rectal ischemia requiring emergency surgery, as seen in this case. ³ In addition, non-surgical complications have also been reported. Eberspacher et al described a case of rectal ischemia leading to severe rectal stenosis, with continued prolapsing and bleeding internal hemorrhoids. This underscores the risk of long-term tissue damage and functional impairment, even in cases where ischemia does not necessitate emergent surgical intervention. ⁴ This case report demonstrates an unusually extensive pattern of ischemia involving both proximal and distal segments of the colon, including full-thickness necrosis of the sigmoid and distal rectum. Notably, ischemia extended to within 7 cm of the anal verge, suggesting a more proximal embolization site with unintended collateral compromise affecting more distal rectal vasculature than typically implicated in standard superior rectal artery embolization. To our knowledge, this degree of distal ischemic injury requiring total proctocolectomy has not been previously reported, thereby highlighting the potential for catastrophic complications even in technically successful embolization cases.

Similar embolization techniques, including those for lower gastrointestinal bleeding, have been established for a longer period and are more extensively studied. Numerous studies have evaluated technical success rates, ischemic complications, the relationship between embolization materials and ischemic outcomes, as well as rebleeding and complication rates in relation to procedural familiarity. In contrast, hemorrhoidal embolization remains a relatively novel intervention with limited operator experience. Consequently, large-scale studies assessing optimal embolization techniques and associated complication rates are still lacking.

The available literature suggests that hemorrhoid embolization is a technically feasible and effective procedure, with a high success rate and notable improvements in patient symptoms. However, the potential for severe ischemic complications necessitates careful patient selection and procedural considerations. This case underscores the need for vigilance in identifying high-risk anatomy, potential distal embolic spread, or non-target perfusion territory compromise. Further research is needed to refine embolization techniques, identify high-risk patients, and establish guidelines to mitigate ischemic injury while maintaining the benefits of this approach.