Kaiser Permanente Los Angeles Medical Center Rosemead, CA, United States
Tri M. Tran, MD1, Sara Javaherifar, MD2, Karl Kwok, MD2, Elizabeth Dong, MD2, Rex Parker, MD2, Vikram Attaluri, MD2, Harpreet Sekhon, MD2 1Kaiser Permanente Los Angeles Medical Center, Rosemead, CA; 2Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
Introduction: Cavernous hemangiomas of the gastrointestinal (GI) tract are rare but are important to recognize as a cause of lower GI bleeding.
Case Description/Methods: A 31-year-old male presented for evaluation of a 20-year history of intermittent, painless rectal bleeding. He underwent colonoscopy at the age of 10 for rectal bleeding and was offered band ligation of hemorrhoids but declined. On initial exam he was found to have external hemorrhoids but was unable to tolerate anoscopy. Complete blood count revealed iron deficiency anemia (hemoglobin of 10.4 g/dL). He was referred to gastroenterology for a colonoscopy which revealed a diffuse area of erythematous mucosa in the rectum resembling a large nevus and large, non-bleeding internal hemorrhoids and possible rectal varices. A biopsy of the rectum revealed colonic mucosa with vascular congestion but no colitis. The patient then underwent flexible sigmoidoscopy with rectal endoscopic ultrasound (EUS) to evaluate for rectal varices. Sigmoidoscopy showed bluish discoloration that was vascular in appearance in the rectal vault but no discrete varices. EUS demonstrated doppler flow consistent with venous hum in the large veins. Given these findings, the patient was sent for a CT scan of his abdomen and pelvis which revealed concentric wall thickening of the sigmoid and rectum with multiple punctate areas of high attenuation within the colonic wall. CT enterography showed circumferential wall thickening extending from the sigmoid through the rectum with punctate wall calcifications. Pathology confirmed the diagnosis of diffuse cavernous hemangiomatosis. The patient underwent laparoscopic robotic assisted proctectomy with loop ileostomy.
Discussion: There are few described cases of cavernous hemangiomas of the colon making them an atypical cause of GI hemorrhage. They are nonmalignant lesions arising from submucosal vascular plexuses with most occurring in the rectosigmoid area. The main symptom is intermittent hematochezia. Diagnosis is difficult however radiographic imaging can be used. Clusters of phleboliths, which are calcified thrombi, if seen in young patients or peculiar locations should raise suspicion. Endoscopy can reveal submucosal and compressible, blue to plum red lesions. Clinical findings in conjunction with diagnostic studies should be used to make a diagnosis. The definitive therapy for colonic hemangiomas is surgical resection. Our patient received a successful laparoscopic proctectomy and diverting loop ileostomy.
Figure: Flexible sigmoidoscopy showing bluish discoloration that was vascular in appearance within the rectal vault and located approximately 25 cm from the anal verge.
Disclosures: Tri Tran indicated no relevant financial relationships. Sara Javaherifar indicated no relevant financial relationships. Karl Kwok indicated no relevant financial relationships. Elizabeth Dong indicated no relevant financial relationships. Rex Parker indicated no relevant financial relationships. Vikram Attaluri indicated no relevant financial relationships. Harpreet Sekhon indicated no relevant financial relationships.
Tri M. Tran, MD1, Sara Javaherifar, MD2, Karl Kwok, MD2, Elizabeth Dong, MD2, Rex Parker, MD2, Vikram Attaluri, MD2, Harpreet Sekhon, MD2. P1282 - A Case Report on Giant Cavernous Hemangiomatosis of the Rectum, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.