A rare cause of disseminated intestinal ulcerations with massive bleeding

A 53 years old man presented with anemia (hemoglobin 4.5 g/dl), hypalbuminemia, elevated CRP and leukocytosis. He reported of a normal gastroscopy and colonoscopy 2 weeks earlier. Repeat gastroscopy showed multiple ulcerations of the whole duodenum with oozing bleeding. CMV and EBV PCR were negative; sCD25 was normal. After initial stabilization by red blood cell transfusion, recurrent bleeding enforced repeated enteroscopies revealing dozens of small oozing ulcerations with polypoid proliferations suspicious for vasculitis. Argon plasma coagulation (APC) was repeatedly performed on all reachable lesions.

The CT scan and angiography confirmed the clinical suspicion of vasculitis or histiocytosis of the small intestine and immunosuppressive treatment was initiated. In spite of that the patient showed successive clinical decline with steadily increasing daily transfusion needs (167 blood bags, 17 platelet bags) up to hemorrhagic shock which lead to an emergency laparotomy. He underwent partial small intestine resection with intraoperative enteroscopy showing the highest lesion density in the duodenum and jejunum.

Meanwhile, histopathological analysis of duodenal biopsies revealed epithelioid angiosarcoma, which was also confirmed in the resected intestinal segment. Since the patient was unfit for chemotherapy, best supportive care was initiated. The patient died a few days later. Angiosarcoma is a very rare neoplasm, mostly located in the skin and soft tissues. Only a few cases have been reported in the intestine but it represents a critical differential diagnosis of hemorrhagic shock due to intestinal bleeding.

Publication History

Article published online:
27 March 2025