Small intestinal vascular malformation bleeding: A case report with imaging findings

Small Intestinal Arteriovenous Malformation Treated by Double-balloon Endoscopy

A 42-year-old man was referred to our hospital because of anemia. The patient underwent gastroscopy and colonoscopy, but no bleeding site was detected. Abdominal contrast-enhanced computed tomography (CT) showed vascular dilatation along the wall of the small intestine. Small bowel capsule endoscopy and antegrade double-balloon endoscopy (DBE) were performed, and the patient was diagnosed with a small intestinal arteriovenous malformation (AVM). The AVM was clipped using DBE. After clipping, abdominal contrast-enhanced CT and small bowel angiography revealed the disappearance of the AVM. DBE may be a viable therapeutic option, helping avoid surgery and its associated risks.

Endoscopic resection of upper gastrointestinal lymphangioma: A single-center experience

OBJECTIVE

Lymphagioma, which in most cases as benign tumors, occurs in head, neck, axilla, and mediastinum. Lymphangioma is exceedingly rare in the upper gastrointestinal tract including esophagus, stomach, and duodenum. However, the clinical characteristics, natural history, and recurrence rate after endoscopic resection remain unclear. This study aims to evaluate the characteristic findings and assess the efficacy of endoscopic techniques in the management of this disease.

METHODS

In this systematic retrospective analysis, we evaluated all 24 cases of upper gastrointestinal lymphangioma resected by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) and diagnosed by histopathology at our hospital from January 2012 to May 2021. We analyzed the results of endoscopy, endoscopic ultrasonography (EUS), CT, histologic examination, and follow-up assessments.

RESULTS

9 male and 15 female patients with esophageal lymphangioma were enrolled in this study, with a mean age of 54.17 ± 11.60 years (range 30-71 years). The lesions' size varied from 2.20 to 40.10 mm, with the median size of 7.83 mm. All patients were evaluated preoperatively, whose endoscopic appearance typically appears as dilated lymphatic channels beneath the surface epithelium of the protrude mucosal or sub-mucosal lesion. Endoscopic ultrasonography revealed the presence of a honeycomb-like or grid-like mass with a heterogeneous echo pattern, and a clear boundary between the lesion and the muscularis propria layer may be helpful for the primary diagnosis of this disease. 22 patients underwent EMR and 2 patient were treated with ESD. Histologic examination revealed that the lesions contained many dilated lymphatic vessels, which confirmed the initial diagnosis of lymphangioma in all patients. No major adverse events were found during the operation or a median follow-up of 43 months (range 13-92).

CONCLUSIONS

Endoscopic ultrasonography has important clinical value for the primary diagnosis of lymphangioma in the upper gastrointestinal tract. This study also suggests that endoscopic resection should be considered as a more minimally invasive, safe, feasible, and effective therapeutic option comparing to laparoscopic surgery.

Gastrointestinal infantile hemangioma: A rare cause of digestive tract bleeding in children to consider

Intestinal hemangiomas are an infrequent cause of gastrointestinal bleeding and chronic anemia in infants, which diagnosis depends on high suspicion. Propranolol has been described as an effective treatment.

Clinicopathological characteristics and prognosis of gastrointestinal vascular tumours

To evaluate the clinicopathological characteristics and prognosis of gastrointestinal vascular tumours. By reviewing the information from the electronic medical record system and pathology database of Hangzhou First People's Hospital affiliated with Zhejiang University School of Medicine and Jiaxing First People’s Hospital from June 2008 to December 2019, 31 patients pathologically diagnosed with vascular tumours were included in this study. The age of onset, sex differences, clinical manifestations, imaging and endoscopic characteristic manifestations, pathological characteristics, treatment methods and prognosis were analysed. The pathological classification was haemangiolymphangioma, haemangioma, and lymphangioma in 8, 14, and 9 cases, respectively. The age of onset was 44–66 years, with no significant difference according to sex (P = 0.583); 32.26% (10/31) of patients had no noticeable symptoms, 37.5% (12/31) of patients had gastrointestinal bleeding, and 6.45% (2/31) of patients, all with lymphangioma, had intestinal obstruction. The lesions were located in and below the duodenum. Endoscopy showed colour differences. Both endoscopic and surgical treatments were safe and effective. The mean survival time was 57.06 ± 35.64 months. Regarding vascular tumours without typical symptoms, the main pathological classification is haemangioma. Vascular tumours are often clinically identified because of bleeding or obstruction and can be treated with endoscopy or surgery. Clinical follow-up is recommended because no invasive manifestations or instances of recurrence were observed.

Small intestinal arteriovenous malformation treated by laparoscopic surgery using intravenous injection of ICG: Case report with literature review

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We report a rare case of small intestinal AVM.

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Distinguishing small intestinal AVM is difficult.

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Intravenous injection of ICG made the location and boundary more clear.

Introduction

Approximately 5 % of gastrointestinal bleeding is due to small intestinal bleeding. Bleeding from small intestinal arteriovenous malformation (AVM) is rare, with few reported cases. Finding the precise location and boundary is difficult during surgery, so we tried using intravenous injection of indocyanine green (ICG). Use of ICG in a case of intestinal AVM is reported here for the first time, with a review of the literature.

Presentation of case

A 48-YEAR-old male had anemia and low hemoglobin level (Hb) 4.0 g/dL. After several examinations including small intestinal endoscopy, capsule endoscopy and angiography, AVM was identified. Preoperative diagnosis was AVM caused by branching of the ileocolic artery (ICA). Meanwhile, macroscopy showed engorgement of the vein in the ileum wall and mesentery, the boundary of which was unclear. We performed intra-operative monitoring with ICG. After intravenous injection of ICG, the boundary and location became clear. The abnormal ileum was 30 cm in length and located 130 cm from the Treitz ligament, which was different from angiographic findings. Pathology showed dilated vascular hyperplasia of the submucosa, tunica and chorionic membrane. Final diagnosis was ileum AVM. The postoperative course was uneventful and gastrointestinal bleeding stopped.

Conclusions

ICG monitoring aided diagnosis and treatment of Ileum AVM, which was treated by laparoscopic surgery.

Arteriovenous malformation in the sigmoid colon of a patient with Cowden disease treated with laparoscopy: a case report

BACKGROUND

Cowden disease is a genetic disorder associated with a mutation of the PTEN gene and is known to be easily complicated by generalized vascular malformations and malignant tumors. However, only a few reports have investigated the relationship between Cowden disease and vascular malformations. We present a case of Cowden disease along with a review of the literature.

CASE PRESENTATION

The patient was a 48-year-old man who visited our hospital complaining of fresh blood in his stools and shortness of breath. Hematological tests showed the patient had severe anemia. On physical examination, white papules-several millimeters in size-were observed between the patient's eyebrows. White papules were also observed on the left corner of his mouth and buccal mucosa. An upper gastrointestinal endoscopy showed densely-packed, white, flat protrusions in the esophagus. While lower gastrointestinal endoscopy revealed a mass accompanied by arterial pulsation in the sigmoid colon. A diagnosis of Cowden disease was confirmed and a laparoscopic sigmoidectomy was performed to address the arteriovenous malformations in the sigmoid colon. Post-surgery, the patient had an unremarkable recovery and was discharged 7 days later.

CONCLUSIONS

We present a very rare case of Cowden disease with arteriovenous malformations occurring in the colon. Surgical resection is believed to be the first choice for treating congenital arteriovenous malformations of the intestines. However, the arteriovenous malformations in the colon in our patient were treated under laparoscopic guidance, making ours the first report describing laparoscopic treatment of colonic arteriovenous malformations occurring in the inferior mesenteric artery. Thus we demonstrate that laparoscopic treatment of arteriovenous malformations in the intestines is a minimally invasive and can be successfully applied in such cases.

Emergent single-balloon enteroscopy for overt bleeding of small intestinal vascular malformation

A 28-year-old man presented with anemia symptoms and intermittent tarry stool passage for three days. No stigmata of hemorrhage were identified using esophagogastroduodenoscopy, ileocolonoscopy, and contrast-enhanced computed tomography. He then developed massive tarry stool passage with profound hypovolemic shock and hypoxic respiratory failure. Emergent angiography revealed active bleeder, probably from the jejunal branches of the superior mesenteric artery, but embolization was not performed due to possible subsequent extensive bowel ischemia. His airway was secured via endotracheal intubation with ventilator support, and emergent antegrade single-balloon enteroscopy was performed at 8 h after clinical overt bleeding occurrence; the procedure revealed a 2-cm pulsating subepithelial tumor with a protruding blood plug at the distal jejunum. Laparoscopic segmental resection of the jejunum with end-to-end anastomosis was performed after emergent endoscopic tattooing localization. Pathological examination revealed a vascular malformation in the submucosa with an organizing thrombus. He was uneventfully discharged 5 d later. This case report highlights the benefit of early deep enteroscopy for the treatment of small intestinal bleeding.