PICTURES IN DIGESTIVE PATHOLOGY

 

Hemangioma of the rectum - How misleading can hematochezia be?

 

 

Sofia Vitor¹, Alexandre Oliveira Ferreira², João Lopes¹ and José Velosa¹

¹ Department of Gastroenterology and Hepatology. Hospital de Santa Maria. Centro Hospitalar Lisboa Norte. Lisboa, Portugal.
² Department of Gastroenterology. Centro Hospitalar do Algarve. Portimão, Portugal

 

 

Case Report

We present the case of an 18-year-old male patient that was referred to our Gastroenterology Department with a history of intermittent painless hematochezia since childhood. During such instances, he was diagnosed with bowel intussusception, eosinophilic gastroenteritis and inflammatory bowel disease at 4, 6 and 8 years old, respectively. He underwent treatment with 5-aminosalicylic acid for two years, without improvement of symptoms. He was then lost to follow-up until our observation.

His physical examination was unremarkable except for digital rectal examination, which found a nodular compressible mass by the palpating finger. Blood tests revealed a mild iron deficiency anemia (hemoglobin 120 g/L, MCV 84 fL, ferritin 3 ng/mL). The colonoscopy showed an extended reddish and bluish multinodular submucosal mass in the rectum (Fig. 1), suggesting diffuse cavernous hemangioma of the rectum (DHCR). The magnetic resonance imaging showed diffuse thickening of the entire rectum extending into the distal sigmoid with the mesorectum revealing multiple serpiginous structures, corresponding to abnormal blood vessels (axial T2 SPAIR weighted) (Fig. 2).

 

 

 

After discussion, we considered to perform a sphincter-sparing procedure, namely pull through transection and coloanal anastomosis. However, intervention was ruled out by the patient because of his fear of anal incontinence and permanent colostomy. We adopted a conservative strategy with clinical surveillance and iron supplementation. At present, the patient remains with intermittent rectal bleeding, referring poor quality of life due to his ongoing symptoms.

 

Discussion

This is a rare case of DHCR. Despite being a benign disease, the management of DHCR requires a sphincter mucosectomy and pull-through coloanal sleeve anastomosis which has become the first-line procedure (1-3). Surgical outcomes are non-expectable in 32% of cases, with permanent sphincter lesion or with incomplete DHCR removal (1). As in this case, surgeons or patients refusal to perform the intervention is common, representing a challenge to the clinical follow-up (4).

 

References

1. Wang HT, Gao XH, Fu CG, et al. Diagnosis and treatment of diffuse cavernous hemangioma of the rectum: Report of 17 cases. World J Surg 2010;34:2477-86. DOI: 10.1007/s00268-010-0691-1.         [ Links ]

2. Chatu S, Kumar D, Du Parcq J, et al. A rare cause of rectal bleeding masquerading as proctitis. J Crohns Colitis 2013;7:99-102. DOI: 10.1016/j.crohns.2012.05.022.         [ Links ]

3. Tan M, Mutch M. Hemangiomas of the pelvis. Clin Colon Rectal Surg 2006;19:94-101. DOI: 10.1055/s-2006-942350.         [ Links ]

4. Hervías D, Turrión JP, Herrera M, et al. Diffuse cavernous hemangioma of the rectum: An atypical cause of rectal bleeding. Rev Esp Enferm Dig 2004;96:346-52. DOI: 10.4321/S1130-01082004000500008.         [ Links ]