Endotherapy for small-bowel recurrent bleeding from a jejunal cavernous hemangioma in an elderly patient

An 83-year-old man, with a history of hypertension, diabetes, and chronic liver disease, presented to the emergency room with fatigue and melena. Blood tests revealed iron-deficiency anemia (Hb 6.5 g/dL). Esophagogastroduodenoscopy (EGD) showed a Forrest III ulcer in the gastric antrum and a small, nonbleeding gastric angiodysplasia, which was treated with argon plasma coagulation. As colonoscopy was unremarkable, the patient was discharged after a few days.

The patient was readmitted 3 months later for recurrence of bleeding. Repeat EGD was negative for bleeding lesions; therefore, capsule endoscopy was performed in <48 hours. Capsule endoscopy showed a 5-mm ulcerated polyp with an adherent clot in the jejunum (Saurin P2 lesion) ([Fig. 1]). A push enteroscopy (SIF-H190; Olympus, Tokyo, Japan) was then performed, confirming the finding of a sessile polyp in the mid jejunum ([Fig. 2]), which was removed en bloc with a braided snare after submucosal injection. Finally, the base was prophylactically closed with hemoclips ([Fig. 3], [Video 1]).

Fig. 1 Capsule endoscopy detected a jejunal P2 lesion (Saurin classification).

Fig. 2 Enteroscopic image of the ulcerated 5-mm polyp in the mid jejunum.

Fig. 3 The cutting base was closed with hemoclips after mucosal resection.

Capsule endoscopy diagnosis and enteroscopic resection of a jejunal cavernous hemangioma in a patient with recurrent bleeding episodes.Video 1

Histology of the specimen showed jejunal nondysplastic ulcerated mucosa, with vascular proliferation and dilation of the capillaries ([Fig. 4]). The results were consistent with the diagnosis of cavernous hemangioma.

Fig. 4 Histological diagnosis of cavernous hemangioma.

Cavernous hemangiomas are rare vascular malformations of mesenchymal origin, potentially involving the small bowel and accounting for 7%–10% of all benign tumors in this gastrointestinal segment [1] [2] [3]. Similarly to other benign small-bowel tumors, cavernous hemangioma may remain asymptomatic for many years before becoming clinically manifest, usually with iron-deficiency anemia or with gastrointestinal bleeding (either overt or occult, often intermittent) [4] [5]. Although small-bowel cavernous hemangioma is mostly common in the young, elderly patients may also be affected [1] [3].

At a 3-month follow-up, the patient remained asymptomatic with no bleeding recurrence, showing that enteroscopic resection is a safe therapeutic option for cavernous hemangioma.

Endoscopy_UCTN_Code_TTT_1AP_2AD

Publication History

Article published online:
08 July 2024

• References

• 1 Yao L, Li LW, Yu B. et al. Cavernous hemangioma of the ileum in a young man: a case report and review of the literature. World J Clin Cases 2022; 10: 10146-10154
• 2 Durer C, Durer S, Sharbatji M. et al. Cavernous hemangioma of the small bowel: a case report and literature review. Cureus 2018; 10: e3113
• 3 Kano T, Fukai S, Okamoto R. et al. An incidentally identified 15 cm cavernous hemangioma of the small intestine: case report and literature review. Int J Surg Case Rep 2021; 84: 106144
• 4 Fantasia S, Cortegoso Valdivia P, Kayali S. et al. The role of capsule endoscopy in the diagnosis and management of small bowel tumors: a narrative review. Cancers 2024; 16: 262
• 5 Pennazio M, Rondonotti E, Despott EJ. et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2022. Endoscopy 2023; 55: 58-95