Endoscopic ultrasound for cavernous hemangioma of rectum.

Lower gastrointestinal (GI) bleed due to hemangioma in rectum is an uncommon problem. A 19-year-old female patient presented with history of recurrent episodes of lower GI bleeding 1-2 times/month for last 3 years. At the time of hospitalization her vital signs were normal and rectal examination revealed frank blood. Investigations revealed a hemoglobin level of 8.9 g/dL and normal coagulation parameters. Colonoscopy showed bluish reddish elevated nodular lesions limited to distal rectum. Magnetic resonance imaging and endoscopic ultrasound showed cavernous hemangioma.

INTRODUCTION

Lower gastrointestinal (GI) bleed due to hemangioma in rectum is an uncommon problem. The routine evaluation includes endoscopic examination where a classical appearance is seen. A hemangioma generally has a feeding and draining vessel and the collection of contrast in hemangioma helps in its identification during computed tomography (CT) scan or magnetic resonance imaging (MRI). This case reports the endoscopic ultrasound (EUS) findings of hemangioma in rectum.

CASE REPORT

A 19-year-old female patient presented with history of recurrent episodes of lower GI bleeding 1-2 times/month for last 3 years. At the time of hospitalization her vital signs were normal and rectal examination revealed frank blood. Investigations revealed a hemoglobin level of 8.9 g/dL and normal coagulation parameters. Colonoscopy showed bluish reddish elevated nodular lesions limited to distal rectum [Figure 1 and Video 1]. MRI of rectum showed hyper intense signals in the anterior wall [Figure 2]. The radial ultrasound was able to demonstrate vascular signal in the submucosa of anterior wall of rectum [Figure 3]. Real time EUS imaging was able to trace an outflowing vessel through the left lateral wall of rectum for a distance of about 3 cm [Video 2]. Application of pulse Doppler confirmed the venous nature of the outflowing vessel [Figure 4]. Linear EUS showed a submucosal vascular lesion in the anterior wall of rectum supplied by an inflowing artery [Figure 5 and Video 3]. A biopsy of the lesion showed numerous dilated vascular spaces within lamina propria and submucosa [Figure 6].

Figure 1

Colonoscopy showed bluish reddish elevated nodular lesions limited to distal rectum. the lesion was seen in anterior wall

Figure 2

Magnetic resonance imaging of rectum showed hyper intense signals in the anterior wall (green arrow)

Figure 3

The radial ultrasound of rectum showed vascular signal in the submucosa of anterior wall of rectum

Figure 4

Application of pulse Doppler confirmed the venous nature of the outflowing vessel in the anterior wall of rectum

Figure 5

Linear endoscopic ultrasound showed a submucosal vascular lesion in the anterior wall of rectum supplied by an inflowing artery

Figure 6

A biopsy of the lesion showed numerous dilated vascular spaces within lamina propria and submucosa

Cavernous hemangioma is an uncommon entity responsible for <1% of lower GI bleed. Diagnosis is best established by endoscopic visualization of a blood filled hemangioma that has appearance of plum red nodules or vascular congestion.[12] CT scan and MRI can also be used for diagnosis and evaluation of the extent. In this case the diagnosis was suspected by endoscopic appearance and MRI and continuous color Doppler EUS of the lesion provided additional information of presence of a vascular lesion [Figures 3–5, Videos 2 and 3]. The patient was referred for surgical resection of rectum and coloanal anastomosis.