CLINICAL CHALLENGES AND IMAGES IN GI Grace Elta and Robert J. Fontana, Section Editors
A Rare Cause of Obscure Gastrointestinal Bleeding Jun Jie Ng, Joel Wen-Liang Lau, and Asim Shabbir Department of General Surgery, University Surgical Cluster, National University Hospital, Singapore
Question: A 33year-old man presented with episodic melena for 3 months associated with worsening exertional dyspnea and lethargy for 2 weeks. Clinical examination revealed marked conjunctival pallor. No masses were felt on abdominal or rectal examination. Hemoglobin level on admission was 3.9 g/dL and red blood cell indices revealed a microcytic and hypochromic erythrocyte profile. The patient received a blood transfusion in view of his symptoms. Esophagogastroduodenoscopy was normal and colonoscopy revealed melenic stains upon intubation of the terminal ileum. Single balloon enteroscopy performed revealed a 2-cm polypoidal lesion with a “strawberry-like” mucosal pattern in the proximal jejunum (Figure A). The lesion was endoscopically tattooed and hemoclips were placed distal to the lesion for future identification. A computed tomography scan of the abdomen showed a 2-cm polypoidal mass in the jejunum with no avid enhancement, calcification, or central necrosis (Figure B). What is the diagnosis of this polypoidal lesion? Look on page 41 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2015.09.046
Gastroenterology 2016;150:40–41
CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 1 (page 40): Small Bowel Lymphangioma
The patient underwent a laparoscopic small bowel resection. The lesion was located at the proximal jejunum by identification of the tattoo and adjacent hemoclips, after which resection of the lesion was performed with clear proximal and distal margins (Figure C). A functional end-to-end stapled small bowel anastomosis was created. Histopathologic examination of the resected specimen revealed a 2.2 2.0-cm sessile polypoidal mass composed of numerous lymph-filled, cystically dilated, thin-walled, interconnecting cavernous spaces within the lamina propria and submucosa, consistent with a small bowel lymphangioma (Figure D). The patient recovered well and was discharged 4 days after surgery. Small bowel lymphangiomas are extremely rare causes of obscure gastrointestinal bleeding. Lymphangiomas are lymphatic malformations that usually present within the pediatric age group as neck or axillary masses. Lymphangiomas affecting the abdominal cavity are rare and, among them, symptomatic intramural small bowel lymphangiomas are even more uncommon, and have only been reported several times in the literature.1 Most small bowel lymphangiomas are asymptomatic, but some can present as gastrointestinal bleeding, abdominal pain, or as a lead point for intussusception.2 Small bowel lymphangiomas are thought to be a result of a congenital malformation causing sequestration of lymphatic vessels during organogenesis, but some authors have postulated that they could be postinflammatory or a result of abdominal trauma, surgery, radiation, or lymphatic obstruction. Complete operative resection is the treatment of choice to prevent future recurrence of gastrointestinal bleeding, but treatment with endoscopic polypectomy, hemoclipping, or argon plasma coagulation have also been described.3
References 1. 2. 3.
Suthiwartnarueput W, Kiatipunsodsai S, Kwankua A, et al. Lymphangioma of the small bowel mesentery: a case report and review of the literature. World J Gastroenterol 2012;18:6328–6332. Onozato W, Nakamura T, Hatate K, et al. A case of lymphangioma of the ileum presenting with intussusception. Jpn J Gastroenterol Surg 2007;40:1531–1535. Kida A, Matsuda K, Hirai S, et al. A pedunculated polyp-shaped small-bowel lymphangioma causing gastrointestinal bleeding and treated by double-balloon enteroscopy. World J Gastroenterol 2012;18:4798–4800.
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).
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A Rare Cause of Obscure Gastrointestinal Bleeding Jun Jie Ng, Joel Wen-Liang Lau, and Asim Shabbir Department of General Surgery, University Surgical Cluster, National University Hospital, Singapore
Question: A 33year-old man presented with episodic melena for 3 months associated with worsening exertional dyspnea and lethargy for 2 weeks. Clinical examination revealed marked conjunctival pallor. No masses were felt on abdominal or rectal examination. Hemoglobin level on admission was 3.9 g/dL and red blood cell indices revealed a microcytic and hypochromic erythrocyte profile. The patient received a blood transfusion in view of his symptoms. Esophagogastroduodenoscopy was normal and colonoscopy revealed melenic stains upon intubation of the terminal ileum. Single balloon enteroscopy performed revealed a 2-cm polypoidal lesion with a “strawberry-like” mucosal pattern in the proximal jejunum (Figure A). The lesion was endoscopically tattooed and hemoclips were placed distal to the lesion for future identification. A computed tomography scan of the abdomen showed a 2-cm polypoidal mass in the jejunum with no avid enhancement, calcification, or central necrosis (Figure B). What is the diagnosis of this polypoidal lesion? Look on page 41 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2015.09.046
Gastroenterology 2016;150:40–41
CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 1 (page 40): Small Bowel Lymphangioma
The patient underwent a laparoscopic small bowel resection. The lesion was located at the proximal jejunum by identification of the tattoo and adjacent hemoclips, after which resection of the lesion was performed with clear proximal and distal margins (Figure C). A functional end-to-end stapled small bowel anastomosis was created. Histopathologic examination of the resected specimen revealed a 2.2 2.0-cm sessile polypoidal mass composed of numerous lymph-filled, cystically dilated, thin-walled, interconnecting cavernous spaces within the lamina propria and submucosa, consistent with a small bowel lymphangioma (Figure D). The patient recovered well and was discharged 4 days after surgery. Small bowel lymphangiomas are extremely rare causes of obscure gastrointestinal bleeding. Lymphangiomas are lymphatic malformations that usually present within the pediatric age group as neck or axillary masses. Lymphangiomas affecting the abdominal cavity are rare and, among them, symptomatic intramural small bowel lymphangiomas are even more uncommon, and have only been reported several times in the literature.1 Most small bowel lymphangiomas are asymptomatic, but some can present as gastrointestinal bleeding, abdominal pain, or as a lead point for intussusception.2 Small bowel lymphangiomas are thought to be a result of a congenital malformation causing sequestration of lymphatic vessels during organogenesis, but some authors have postulated that they could be postinflammatory or a result of abdominal trauma, surgery, radiation, or lymphatic obstruction. Complete operative resection is the treatment of choice to prevent future recurrence of gastrointestinal bleeding, but treatment with endoscopic polypectomy, hemoclipping, or argon plasma coagulation have also been described.3
References 1. 2. 3.
Suthiwartnarueput W, Kiatipunsodsai S, Kwankua A, et al. Lymphangioma of the small bowel mesentery: a case report and review of the literature. World J Gastroenterol 2012;18:6328–6332. Onozato W, Nakamura T, Hatate K, et al. A case of lymphangioma of the ileum presenting with intussusception. Jpn J Gastroenterol Surg 2007;40:1531–1535. Kida A, Matsuda K, Hirai S, et al. A pedunculated polyp-shaped small-bowel lymphangioma causing gastrointestinal bleeding and treated by double-balloon enteroscopy. World J Gastroenterol 2012;18:4798–4800.
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).
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