A 76-year-old woman presented with recurrent right lower quadrant
pain associated with decreased appetite and weight loss. An abdominal computed
tomography (CT) scan without contrast injection (iodine allergy) showed a
thickening of the cecal wall with infracentimetric regional lymph nodes ([Fig. 1]).
Fig. 1 A computed tomography of
the abdomen showing a thickening of the cecal wall.
Colonoscopy depicted a 4 × 2-cm indurated and
ulcerated lesion with necrotic features facing the ileocecal valve ([Fig. 2]).
Fig. 2 Endoscopic view of the
ulceronecrotic lesion facing the ileocecal valve.
Laboratory tests were normal except for a slightly elevated
carcinoembryonic antigen at 9.6 ng/mL (normal value:
< 4.5 ng/mL). The pathologic analyses from the biopsies showed
necrotic tissue without signs of malignancy. Despite negative histology, given
the clinical presentation, and endoscopic and imaging studies, the patient
underwent a right hemicolectomy. Macroscopic study of the resected specimen
found an ulcerative lesion of size 3.5 cm near the ileocecal valve.
Microscopic examination revealed richly vascularized granulation tissue ([Fig. 3]) containing arterialized veins (arrows).
Fig. 3 Microscopic examination
of the surgical specimen revealed richly vascularized tissue containing
arterialized veins (arrows).
The mucosa and the submucosa exhibited increased numbers of dilated
and deformed vessels ([Fig. 4]).
Fig. 4 Microscopic examination
of the surgical specimen showing increased numbers of dilated and deformed
vessels within the mucosa and the submucosa.
In the absence of nonsteroidal anti-inflammatory drug use and
ischemic findings, all these pathologic features are consistent with the
diagnosis of ulcerated angiodysplasia of the cecum.
Typical lesions of angiodysplasia are red and small (diameter
4 – 8 mm) [1]. Colonoscopy is
the gold standard for detecting symptomatic or asymptomatic lesions. It has a
sensitivity of 68 % with a predictive positive value of
90 % [2]. Two cases of angiodysplasia have
been described with a radiologic aspect typical of adenocarcinoma
[3]
[4]. In both cases, it presented
as a sessile mass, with adjacent ulceration in one case, and surgery was
performed. The originality of this case comes first from the clinical
presentation – a 76-year-old woman with no presenting blood loss but with
abdominal pain, lack of appetite and weight loss – features that are very
unusual in the setting of angiodysplasia, and second from its atypical
endoscopic presentation mimicking adenocarcinoma.
Endoscopy_UCTN_Code_CCL_1AD_2AF
