Pyogenic Granuloma: An Unusual Cause of Massive Gastrointestinal Bleeding from the Small Bowel

Abstract

G astrointestinal (GI) bleeding in the small intestine -distal to the duodenum -is an uncommon entity and is responsible for 4% of all cases of GI bleeding (1). The most common etiologies for small intestinal bleeding are angiodysplasias and tumours, responsible for approximately 70% and 10% of cases, respectively (1,2). Pyogenic granuloma (PG) is a common inflammatory vascular tumour of the skin and oral cavity that has rarely been described in the GI tract as a source of obscure and overt bleeding. In the present report, we describe the first case of massive GI bleeding caused by a small bowel PG, and we review the relevant literature to date regarding the clinical presentation, diagnosis and management of this rare GI lesion. Case presentationThe case of a 78-year-old Caucasian man with longstanding anemia (hemoglobin 80 g/L to 100 g/L) followed by a hematologist for suspected myelodysplasia is reported. On worsening of his anemia, and with decreasing serum ferritin and iron saturation levels, he was diagnosed with iron deficiency anemia and a GI source of blood loss was suspected. Diagnostic esophagogastroduodenoscopy, colonoscopy and small bowel follow-through did not reveal the source of bleeding. A technetium 99m-tagged red blood cell scan was performed and suggested bleeding in the right upper quadrant; however, the source was not clearly identified as being in the large or small bowel.Shortly thereafter, the patient presented to hospital with presyncope, hemodynamic instability and large volume melena. He was hospitalized and required transfusion of eight units of packed red blood cells over a 24 h period. His nadir hemoglobin was 62 g/L, at which point he was transferred to the Health Sciences Centre at the University of Manitoba, Winnipeg, Manitoba, for further assessment and management. An urgent small bowel push enteroscopy identified a 2 cm polypoid lesion approximately 20 cm into the jejunum. The lesion was reddish-blue in colour, with a white coating and superficial ulceration (Figure 1 Small bowel hemorrhage is responsible for approximately 4% of all cases of gastrointestinal bleeding. The etiology of bleeding from the small bowel is a tumour in approximately 10% of cases. Pyogenic granuloma is a common inflammatory vascular tumour of the dermis, which rarely occurs in the gastrointestinal tract. Pyogenic granuloma is a rare cause of overt or obscure small bowel bleeding. The present paper reports the first case of pyogenic granuloma presenting as a massive gastrointestinal bleed, and reviews the relevant literature to date regarding the clinical presentation, diagnosis and management of this rare gastrointestinal lesion.

Pyogenic Granuloma of the Ileum Diagnosed by Double-balloon Enteroscopy

“…PGs are benign granulomas like telangiectaticum or lobular capillary hemangiomas. They occur mostly in the skin and are rarely found in the intestine (3)(4)(5)(6).…”

Esophageal Pyogenic Granuloma: Endosonographic Findings and Endoscopic Treatments

“…Pyogenic granuloma is a common lesion in the skin and oral mucosa, but rarely found in the alimentary tract 3. Only 42 cases of pyogenic granuloma in the alimentary tract have been reported to date; the granuloma was located in the esophagus in 23 of these cases 2-6.…”

“…EMR and endoscopic snare polypectomy are the most favorable treatment options for esophageal pyogenic granulomas 3,6. In our patients, the lesions were completely resected using traditional EMR or EMR with a ligation device.…”

Urinary bladder pyogenic granuloma: a case report

“…It usually presents as a solitary, rapidly growing papule or polyp-like pedunculated lesion that bleeds easily because of its extreme vascularity and eroded surface [4-6]. Pyogenic granuloma has been histologically classified as a lobular capillary hemangioma, which is similar to a capillary-type hemangioma.…”