An Unusual Cause of Obscure Gastrointestinal Bleeding

Abstract

Question: An 88year-old woman presented to our hospital with episodic melena, fatigue, and shortness of breath for 6 months. Her medical history was significant for hypertension, for which she had been prescribed enteric-coated aspirin and amlodipine. A physical examination was unremarkable except for pale conjunctiva. Her hemoglobin level was around 8 g/dL, and serum platelet count, coagulation factors, and other chemistry tests were all within normal limits. Esophagogastroduodenoscopy and colonoscopy did not reveal an obvious bleeding source. Video capsule endoscopy showed fresh blood at the proximal jejunum. Antegrade single-balloon enteroscopy demonstrated a 3-cm lobular circumferential mass with a lymphangiectatic appearance and mild oozing in the proximal jejunum (Figure A). Several submucosal lesions of <1 cm were also noted in the distal duodenum and proximal jejunum (Figure B). What is your diagnosis and management? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Single-Balloon-Assisted Enteroscopy With Endoscopic Mucosal Resection of a Bleeding Jejunal Lymphangioma

“… 4 Surgical resection is the standard for the management of symptomatic jejunal and ileal lymphangiomas. 1 , 2 Similarly, there are only 2 other reported cases of endoscopically treated small bowel lymphangiomas, 4 , 5 demonstrating that endoscopic management is feasible with experienced endoscopists.…”

“…1 Typically asymptomatic, lymphangiomas can cause gastrointestinal bleeding, intussusception, or protein-losing gastroenteropathy. [1][2][3] We present a case of occult gastrointestinal bleeding caused by a lymphangioma, successfully removed by endoscopic mucosal resection by an upper single-balloon-assisted enteroscopy.…”

Small Bowel Lymphangioma - A Rare Cause of Small Bowel Bleeding

“…The cavernous type can be fast growing and is the most likely subtype to cause gastrointestinal bleeding. Symptomatic small bowel lymphangiomas are a very rare finding in adults and less than 20 cases have been described in the literature to date [2][3][4].…”