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

CASE REPORT

Lymphangiomas are rare tumors with <1% found in the jejunum or ileum.[1] Typically asymptomatic, lymphangiomas can cause gastrointestinal bleeding, intussusception, or protein-losing gastroenteropathy.[1-3] 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.

A healthy, asymptomatic 75-year-old man had routine tests that revealed a new normocytic anemia: hemoglobin 12.9 g/dL, previously 15 g/dL. Upper endoscopy and colonoscopy were normal. Over 6 months, he developed weakness, worsened microcytic anemia (hemoglobin 8.5 g/dL), and iron deficiency. Celiac disease serology was negative. Video capsule endoscopy captured a white-speckled lesion with fresh blood at 25% of the small bowel transit (Figure 1). An upper single-balloon-assisted enteroscopy localized the polyp in the proximal jejunum (Figure 2). The polyp was lifted with hetastarch-epinephrine-methylene blue, and en bloc endoscopic mucosal resection was performed (Figure 3). Pathology confirmed a lymphangioma (Figure 4). The patient's hemoglobin normalized and symptoms resolved.

Figure 1.

A submucosal polypoid lesion with a white and red speckled surface was captured in 1 single image.

Figure 2.

An upper single-balloon-assisted enteroscopy localized a 12 mm white-speckled, bleeding, sessile polyp in the proximal jejunum.

Figure 3.

The polyp submucosa was injected with a long-lasting lifting agent and resected en bloc using snare cautery endoscopic mucosal resection.

Figure 4.

Pathology revealed dilated lymphatic vessels (stars) in the lamina propria consistent with a lymphangioma.

Bleeding from lymphangioma is proposed by lymphatic obstruction, increasing lymphatic-venous pressures.[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.

DISCLOSURES

Author contributions: J. Trieu and A. Dua wrote the original manuscript. N. Gupta, RP Venu, and M. Venu critically reviewed the manuscript before submission. Mukund Venu is the article guarantor.

Financial disclosure: None to report.

Previous presentation: The case was submitted to Digestive Disease Week 2021 but not presented. It received an honorable mention from the ASGE. DDW 2021 was a virtual conference held on May 21-24.

Informed consent was obtained for this case report.