Hemorrhoid embolization for chronic grade 3 bleeding
A man in his 30s had chronic rectal bleeding from grade 3 internal hemorrhoids and a haemoglobin below 10 g/dL. The superior rectal artery branches were embolized with a combination of microsphere particles and coils; at one month the bleeding had decreased and the haemoglobin had risen. Longer-term follow-up is a separate question.
Continuous bleeding and a falling haemoglobin
A man in his 30s presented with chronic, continuous rectal bleeding from grade 3 internal hemorrhoids. The ongoing blood loss had brought his haemoglobin below 10 g/dL.
He was looking for a solution that did not involve surgery. Taken together, the clinical assessment and the available findings suggested he was a candidate for superior rectal artery embolization.
The superior rectal artery branches feeding the hemorrhoids on DSA
Angiography of the inferior mesenteric artery (IMA) showed the superior rectal artery and the terminal branches supplying the hemorrhoidal cushions. Superselective DSA runs set out the distribution of the arterial branches to be treated.
On the final check images the target superior rectal artery branches were closed, while the non-target arterial branches were preserved.
A catheter-based option for a patient who did not want surgery
In grade 3 internal hemorrhoids the choice of treatment weighs the severity of the bleeding, prolapse, anaemia, coexisting conditions and the patient's own preference together. Here the fact that continuous bleeding had driven the haemoglobin down made the need for treatment clear.
Because he did not want surgery, superior rectal artery embolization — which aims to reduce the arterial inflow to the hemorrhoids through a catheter — was planned as a minimally invasive option.
Particle and coil embolization through a 5F femoral access
The procedure began with a 5F sheath in the femoral artery. The inferior mesenteric artery was catheterised first; a microcatheter was then advanced superselectively into the superior rectal artery and the branches feeding the hemorrhoids.
The target branches were embolized first with microsphere particles and then with coils. The procedure was ended once a final check angiogram confirmed that each separately treated branch was closed and that the non-target arterial circulation was preserved.
The procedure on DSA: four steps from feeding branches to final check
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What you see Contrast fills the terminal branches running from the superior rectal artery to the hemorrhoidal cushions.
Why it matters This run was used to establish how many target branches there were and how they were distributed.
During the procedure The opening DSA run through the IMA, showing the superior rectal artery branches that feed the hemorrhoids. -
What you see Coil material is visible in the target branch as the flow through it to the hemorrhoidal cushion decreases.
Why it matters The intention was to treat the first feeding branch in a controlled way, at both distal and proximal levels.
During the procedure The first target superior rectal artery branch being embolized with a combination of microsphere particles and coils. -
What you see Coils placed in the different target branches, and the reduced flow through them.
Why it matters Treating each arterial feeder separately was necessary to reduce the residual flow reaching the hemorrhoidal cushions.
During the procedure The other superior rectal artery branches feeding the hemorrhoids being embolized separately with particles and coils. -
What you see The coiled target superior rectal artery branches are closed while the non-target arterial branches continue to fill.
Why it matters The final run confirmed that the treatment targets were closed and that the non-target circulation was intact.
After the procedure The final check DSA run through the IMA after embolization: the target superior rectal artery branches are closed and the other arterial branches are preserved.
Same-day discharge, less bleeding at one month
The patient was observed for four to five hours after the procedure and discharged the same day.
At the one-month review there was a clear reduction in the amount of bleeding and a rise in haemoglobin. These findings were consistent with an early clinical and laboratory response; longer follow-up matters for judging whether the bleeding control lasts.
What this case teaches
Chronic hemorrhoidal bleeding does more than reduce quality of life: it can also drive the haemoglobin down. Reading the change in haemoglobin alongside what the patient reports about the bleeding therefore gives a more objective picture of the response to treatment.
In this case, after superselective embolization of the superior rectal artery branches with microsphere particles and coils, one month brought both less bleeding and a higher haemoglobin.
What this means for the patient
Superior rectal artery embolization is a catheter-based option that aims to reduce hemorrhoidal bleeding in suitable patients without an incision.
It is not the only option for everyone with grade 3 hemorrhoids. The degree of prolapse, the severity of the bleeding, anaemia, previous treatments and the patient's own preferences all belong in a joint proctology and interventional radiology assessment.
Risks and alternatives
Possible risks
Bleeding or bruising at the catheter site may occur. Rectal ulceration or reduced blood supply to the bowel are important potential harms; bleeding may persist and another treatment may be needed.
Other options
Fibre, stool-softening measures and medicines, rubber-band ligation or other office procedures, and surgery when indicated. Rectal bleeding needs assessment for other causes.
NICE considers the evidence on safety and benefit insufficient and recommends this procedure only in a research setting in the UK. Any proposal here needs an individual discussion of this uncertainty.
Clinical source: NICE
This is one patient. Imaging is anonymised and published with that patient’s written consent. Individual results vary, and nothing here is a prediction of your own outcome or a substitute for a consultation.