P4834 - Coil Embolization of Two Branches of the Left Middle Rectal Artery in a Patient With Metabolic-Associated Steatohepatitis (MASH) Having Chronic Hemorrhoidal Rectal Bleed

Emelyn Martinez, MD¹, Adam Atoot, MD¹, Jaskirat Virk, MD², Vignesh Krishnan, MD¹, Vishal Pande, MS³, Areej Belal, MD¹, James Liu, MD¹, Priyanka Pulipaka, MD¹, Shruthi Badam, MD¹, Ruchi Bruju, MD^1
1Hackensack Meridian Health - Palisades Medical Center, North Bergen, NJ; ²Hackensack University Medical Center, Hackensack, NJ; ³ESIC Medical College and Hospital, Kalnoor, Karnataka, India

Introduction: In the presence of portal hypertension, rectal bleeding can be caused by submucosal rectal varices. Surgery usually is the mainstay treatment for symptomatic hemorrhoids that have failed conservative management. However, for unfit patients, such as those with liver cirrhosis and MELD score above 15 points, options for treatment are very few. In a recent case, a coil embolization of two branches of the left middle rectal artery was performed as a rescue therapy for recurrent rectal bleeding refractory to conservative management in a patient with Metabolic-associated Steatohepatitis (MASH) with a MELD score of 31.

Case Description/Methods: A 68-year-old female with a past medical history of MASH cirrhosis presents to the emergency department for the evaluation of low hemoglobin (7.4 g/dL) in the setting of chronic hemorrhoidal rectal bleed. CTA of abdomen and pelvis found prominent rectal hemorrhoids without sign of active arterial bleed. Patient required blood transfusion and given that she is not a candidate for TIPS due to high MELD score, IR was consulted for the evaluation of hemorrhoidal artery embolization. Coil embolization of two branches of the left middle rectal artery was performed. Patient tolerated the procedure well and was discharged on stable conditions with instructions to return if bleeding reappeared to consider embolization of additional rectal arterial branches as needed.

Discussion: In patients who are medically unfit for surgery as is in this case, embolization of the hemorrhoidal arteries is an emerging approach to manage such high-risk patients. With this technique, the terminal branches of the superior rectal artery (SRA) are embolized through an endovascular approach. After obtaining an angiogram of the superior rectal artery network and its anastomoses with inferior rectal artery (IRA) through femoral artery catheterization, metallic coils and synthetic microparticles act as embolic agents to occlude the distal branches. The current available literature supports the efficacy, feasibility and safety of SRA embolization for hemorrhoids. Recurrence of bleeding is the main reason for clinical failure, which can be treated by repeating the procedure as needed.


Disclosures:


Emelyn Martinez, MD¹, Adam Atoot, MD¹, Jaskirat Virk, MD², Vignesh Krishnan, MD¹, Vishal Pande, MS³, Areej Belal, MD¹, James Liu, MD¹, Priyanka Pulipaka, MD¹, Shruthi Badam, MD¹, Ruchi Bruju, MD¹. P4834 - Coil Embolization of Two Branches of the Left Middle Rectal Artery in a Patient With Metabolic-Associated Steatohepatitis (MASH) Having Chronic Hemorrhoidal Rectal Bleed, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.