Repurposing the Incidental Detection of Internal Hemorrhoids as an Independent Predictor of Coronary Artery Disease Risk

Research Article

J Dis Markers. 2023; 8(2): 1054.

Repurposing the Incidental Detection of Internal Hemorrhoids as an Independent Predictor of Coronary Artery Disease Risk

Eroglu E¹*; Turkmen I²; Algul S³; Reddy V4; Altinli E¹

1Department of General Surgery, Memorial Hospital, Bahcelievler, Istanbul, Turkey

2Department of Radiology, Memorial Hospital, Bahcelievler, Istanbul, Turkey

3Department of Physiology, Yuzuncu Yil University, School of Medicine, Van, Turkey

4Heersink School of Medicine, University of Alabama, Birmingham, AL, USA

*Corresponding author: Eroglu E Department of General Surgery, Memorial Hospital, Bahcelievler, Istanbul, Turkey Tel: +90 212 408 45 45; Fax: +90 212 654 76 28 Email: erogluersanmd@gmail.com

Received: April 05, 2023 Accepted: May 12, 2023 Published: May 19, 2023

Abstract

The relationship between anal canal hemorrhoids and cardiovascular diseases has been demonstrated in retrospective population-based studies. Despite the etiological similarities, the real-time correlation between hemorrhoids and cardiovascular risk is not known yet. We aimed to investigate the importance of incidentally detected internal hemorrhoids in predicting cardiovascular risk as determined by Carotid Intima-Media Thickness (CIMT) and Epicardial Fat Thickness (EFT) measurements. Totally, 269 patients who underwent colonoscopy for benign reasons were enrolled in this single-center cross-sectional study. The groups with and without hemorrhoids were compared for CIMT, EFT, and other risk factors. Independent predictors for increased CIMT and EFT values were evaluated by regression analysis. The mean age of the patients was 43.5±13.9 years and 34.6% were female. The prevalence of internal hemorrhoids was 30.5% (n=82). The presence of hemorrhoids was one of the independent predictors for increased CIMT along with hypertension and smoking (OR: 4.29, 2.63, and 2.36, respectively). The independent predictors of increased EFT were female gender, high body mass indexes, and high platelet levels (OR: 2.27, 1.47, and 1.01 respectively). Incidentally diagnosed internal anal canal hemorrhoids, albeit for other reasons, can be a useful predictor for the risk of atherosclerosis and cardiovascular diseases.

Keywords: Hemorrhoid; Carotid intima-media thickness; Epicardial fat; Atherosclerosis

Abbreviations: BMI: Body Mass Indexes; CI: Confidence Interval; CIMT: Carotid Intima Media Thickness; CT: Computed Tomography; EFT: Epicardial Fat Thickness; IBD: Inflammatory Bowel Disease; MRI: Magnetic Resonance Imaging; NS: Non-Significant; OR: Odds Ratio; SD: Standard Deviation; VEGF: Vascular Endothelial Growth Factor

Introduction

Although anal canal hemorrhoids are among the most common clinical conditions in the general population, most patients are asymptomatic. While patients who have thrombosed external hemorrhoids and advanced internal hemorrhoids are admitted with bleeding, pain, or difficulty in defecation, patients who have early-stage internal hemorrhoids are incidentally diagnosed during proctoscopy or colonoscopy. The most common etiologies are dietary habits, sliding anal canal lining due to constipation, abdominal obesity, alcohol intake, and/or increased pressure on the lower rectum [1-3]. The most prominent demonstrated physiological abnormality is an increased resting anal canal pressure along with elevated matrix metalloproteinase activity and a degenerated collagen structure [4,5]. In addition, a study has shown that increased Vascular Endothelial Growth Factor (VEGF) and Nitric Oxide Synthase (NOS), which indicate increased inflammatory activity, was observed in internal hemorrhoid tissue samples [6,7].

Presently, cardiovascular diseases are also seen as frequently as hemorrhoids. However, cardiovascular disease remains one of the leading causes of death despite developing technology and increasing treatment options as it still cannot be completely prevented due to the increasing incidence of obesity-related sedentary lifestyles [8]. Many asymptomatic patients aged between 40 and 70 are admitted to the hospital with sudden cardiac death or an extensive myocardial infarction. The diagnosis, often determined after the cardiovascular event has occurred, is the main reason for increased mortality and morbidity [9]. In recent years, studies have focused on practical and reliable tests that can be used to predict high-risk populations, apart from the techniques used routinely in diagnosis and screening [10].

Carotid Intima-Media Thickness (CIMT) was investigated in many studies as the earliest predictor of morphologic or functional arterial wall deterioration and atherosclerosis [11]. According to some studies, CIMT measurements reflect the systemic pro-inflammatory state and it can be used as a surrogate marker for atherosclerotic plaque development. Even though routine CIMT measurement is not recommended by the main guidelines, this method is a well-established non-invasive technique with reliable age-sex-adjusted cut-offs to define cardiovascular risk [12].

Epicardial Fat (EF) is the deposit of visceral fat located between the myocardium and pericardium and has been shown to predict the risk of coronary artery disease [13]. EF embryologically develops from the same origin as omental and mesenteric adipose tissue [14]. Adipokines and proinflammatory cytokines released from adipose tissue play an important role in the development of atherosclerosis [15]. EF levels are evaluated as EF Thickness (EFT) with two-dimensional echocardiography or EF volume with cross-sectional methods (MRI or CT). These measurements are useful in predicting the risk of coronary artery disease [13].

However, these methods have not yet been widely used in clinical practice. In a population-based retrospective study on the relationship between hemorrhoids and cardiovascular diseases, it was shown that the risk of cardiovascular events is increased in patients with hemorrhoids [16]. From this point, we hypothesize that, regardless of other proven etiologies, the simultaneous development of these two conditions caused by increased vascular inflammatory stress can be used as a clinical predictor. Our aims in this study are to evaluate the relationship between internal anal canal hemorrhoids and cardiovascular risk as well as to increase awareness among clinicians who are performing colonoscopy about this small finding incidentally revealed during the procedure.

Materials and Methods

Study Design, Patient Enrollment, and Sample Collection

This cross-sectional study included 400 consecutive patients who underwent a colonoscopy for any reason at our hospital from July 2022 to October 2022. Demographic characteristics, chronic diseases, body mass indexes, habits, and drugs used by the patients were recorded. Patients who have chronic inflammatory conditions which may affect CIMT or EF measurements were excluded (Figure 1). In addition, according to the results of colonoscopy, patients with findings such as cancer and inflammatory bowel disease were also excluded as well as patients who had inadequate bowel preparation. Biochemistry and hemogram parameters were evaluated in fasting venous blood samples taken from the remaining 269 patients. The study was conducted in compliance with the principles outlined in the Declaration of Helsinki and was approved by the Institutional Ethics Committee (permit number: 2022/07-11). All patients provided written informed consent.