Gastric pyogenic granuloma: rare entity, usual therapy

Lobular capillary hemangioma, known as pyogenic granuloma, is a benign vascular tumor that generally appears on the skin or in the oral cavity but rarely occurs in the gastrointestinal tract, where it can cause bleeding [1]. Although gastric pyogenic granuloma is rarely reported in the literature, (up to 2016, approximately 50 cases of gastrointestinal pyogenic granuloma in the English literature had been indexed on MEDLINE, including a few cases of gastric involvement), the actual incidence is probably higher [2] [3].

The endoscopic appearance of pyogenic granuloma is usually a single polypoid lesion, smooth and ulcerated; the color ranges from bluish to reddish with a superficial white or opaque film covering. Resection of pyogenic granuloma is necessary in patients with anemia, but post-resection bleeding is a potential complication. The lesions typically involve the mucosa but may extend to the deep layers; thus, preoperative endoscopic ultrasonography is recommended [1] [4] [5].

Histopathologically, pyogenic granuloma is a hemangioma characterized by a lobule-like growth of capillaries with enlarged vascular endothelial cells and inflammatory cell infiltration in the stroma. Granulation tissue may also be present; the main pathological differential diagnosis of pyogenic granuloma includes bacillary angiomatosis, Kaposi’s sarcoma, or inflammatory and/or hyperplastic polyps [1] [3].

We report a case of a 78 year-old Caucasian woman with a medical history significant for ibuprofen use admitted to our department for anemia and melena requiring transfusion. Esophagogastroduodenoscopy revealed a nearly 20-mm pedunculated polyp, strongly hyperemic with a superficial white film, in the gastric body ([Fig. 1]). Endoscopic ultrasonography showed mucosal involvement without deep infiltration ([Fig. 2]).

Fig. 1 20-mm polypoid lesion with a superficial white film covering the head.

Fig. 2 Endoscopic ultrasonography evidence of a hypoechoic lesion arising from the second wall layer with preserved wall layers and no deep infiltration.

We removed the polyp using endoscopic mucosal resection, lifting the lesion with a solution of indigo carmine and epinephrine; in addition, multiple clips were used to close the defect to prevent bleeding ([Video 1]). Histology demonstrated foveolar hyperplasia and lobulated capillary hemangioma, characteristic of pyogenic granuloma ([Fig. 3], [Fig. 4]). Her refractory anemia improved after the procedure.

Video 1 Gastric pyogenic granuloma effectively removed by endoscopic snare resection.

Fig. 3 Numerous thin-walled capillaries of different size lined with endothelial cells are separated by inflammatory stroma (hematoxylin & eosin, × 40).

Fig. 4 ERG positivity, a specific marker for endothelial cells, in contrast with gastric glands, with foveolar hyperplasia surrounding the lesion (immunohistochemistry, × 20)

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Publikationsverlauf

Artikel online veröffentlicht:
04. Februar 2022

• References

• 1 Hayashi Y, Hosoe N, Takabayashi K. et al. Clinical and endoscopic characteristics of pyogenic granuloma in the small intestine: a case series with literature review. Intern Med 2020; 59: 501-505
• 2 Katsurahara M, Kitade T, Tano S. et al. Pyogenic granuloma in the small intestine: a rare cause of obscure gastrointestinal bleeding. Endoscopy 2015; 47: E133-E134
• 3 Val-Bernal JF, Mayorga M, Cagigal ML. et al. Gastric pyogenic granuloma: report of two cases and review of the literature. Pathol Res Pract 2016; 212: 68-71
• 4 Reichert MC, Schuster M, Kim YJ. et al. Recurrent gastrointestinal bleeding due to multiple pyogenic granulomas in the stomach. Am J Gastroenterol 2017; 112: 833
• 5 Meeks MW, Kamal UM, Hammami MB. et al. Gastrointestinal pyogenic granuloma (lobular capillary hemangioma): an underrecognized entity causing iron deficiency anemia. Case Rep Gastrointest Med 2016; 2016: 4398401