Upper Rectal Artery Embolization in the Treatment of Hemorrhoidal Disease

Proposal description 1.1. Hemorrhoids: Epidemiology, Clinical Presentation and Diagnostic Assessment: In the normal anal channel, there are three highly-vascularized areas (pads), forming slight masses in the submucosa made of blood vessels, smooth muscle and elastic and connective tissue, and are located at the left lateral, right anterior and right posterior quadrants, and contribute in anal continence . The term hemorrhoids refers to clinical situations where these hypervascularized pads are abnormal and cause clinical symptoms.

The exact disease prevalence of symptomatic hemorrhoidal disease is difficult to establish, since many symptomatic patients do not seek an assessment, while others assign varied anorectal symptoms as being resulting from hemorrhoids. Some series estimate prevalence between 4 and 40 %. Although many patients will exhibit symptomatic hemorrhoids along life, the peak incidence occurs between 45 and 65 years old and its development prior to 20 years old is rarely frequent . Among the factors related to a higher risk of developing the disease are: pregnancy, white race, females.

Hemorrhoids may be divided as external and internal. External hemorrhoids are covered by anoderm (richly enervated layer), are located distally to the dentate line and their main symptoms are edema, causing discomfort and difficult local hygiene, which may also exhibit an intense pain when thrombosed. Internal hemorrhoids are located proximally to the dentate line and are lined with poorly enervated anorectal mucosa, and rarely cause pain, except when thrombosed and combined with prolapse and necrosis; often their symptoms are prolapse and bleeding.

Internal hemorrhoids may be subdivided into 4 grades: grade 1 are defined by a protuberance in anal channel and may show prolapse beyond the dentate line at great exertion; grade 2 are hemorrhoids prolapsing beyond the dentate line at exertion, but reduced spontaneously; grade 3 are hemorrhoids prolapsing beyond the dentate line, requiring manual reduction; and grade 4 are defined by non-reducing prolapsed hemorrhoids, being at risk of strangulation.

Hemorrhoidal disease diagnosis is based on medical history combined with physical exam and complementary exam. Physical exam should include inspection at exertion, digital rectal exam (which allows an assessment of internal and external hemorrhoids, anal channel tonus assessment, in addition to excluding other diseases, such as neoplasm and sphincter spasm) and anoscopy. Among complementary tests, flexible rectal sigmoidoscopy, colonoscopy, barium enema may be requested at complementary diagnosis, mainly to rule out other diseases.