Baystate Medical Center Springfield, MA, United States
Michael Wagner, DO, Rinad Tabbalat, MD, Nicolas Cal, DO Baystate Medical Center, Springfield, MA
Introduction: Gastrointestinal hemangiomas are benign vascular lesions that can occur anywhere in the gastrointestinal tract but are most common in the rectosigmoid colon. Diffuse cavernous hemangioma of the rectum (DCHR) is an exceedingly rare clinical entity, with approximately less than 200 cases reported in the literature. We present a case of a 61-year-old male with rectal bleeding and clinical evaluation concerning for DCHR. This case highlights DCHR as a rare cause of rectal bleeding, its common endoscopic and radiographic findings, and the possible therapeutic interventions.
Case Description/Methods: A 61-year-old male with a history of intermittent rectal bleeding for 40 years, hemorrhoidectomy at age 20, and prior alcohol abuse presented to the hospital with 3 weeks of bright red blood/clots per rectum and nighttime soiling. He was afebrile, hemodynamically stable and he denied chest pain, shortness of breath, nausea/vomiting, coffee ground emesis, or melena. Abdominal exam was unremarkable, and he was in no acute distress. Labs showed iron deficiency anemia with a normal liver panel, platelet count and INR. Colonoscopy revealed a vascular neoplasm with multiple cords of submucosal veins (distal rectum to 35 cm from the anus) with stigmata of recent bleeding. Upper endoscopy and liver/doppler ultrasound showed no evidence of portal hypertension. CT and MRI suggested DCHR given findings of marked circumferential bowel wall thickening of the rectosigmoid colon, with mural calcifications. The patient declined surgical intervention, electing for close monitoring, and as needed blood transfusions.
Discussion: DCHR often presents in children and young adults as iron deficiency anemia with intermittent, recurrent painless rectal bleeding. DCHR is often misdiagnosed as hemorrhoids or ulcerative colitis, with many patients (up to 80%) undergoing inappropriate interventions. DCHR is diagnosed by imaging and endoscopic evaluation. CT shows dimensions of the lesion and involvement of adjacent structures. MRI shows bowel wall thickening (nodular or uniform), and the lesion is usually hypointense on T1-weighted and hyperintense of T2-weighted images. Colonoscopy shows multiple soft, compressible nodules with dilated and engorged submucosal veins. Biopsy is not advised given the risk for brisk bleeding. Treatments options include complete surgical resection (definitive therapy), balloon-occluded antegrade transvenous obliteration (BATO), cryotherapy, selective embolization, argon fulguration or tranexamic acid.
Figure: Figure 1. Panels A&B: Colonoscopy showing multiple cords of large and bulging submucosal veins consistent with a large vascular neoplasm; stigmata of recent bleeding was also noted. Panel C: CT abdomen/pelvis with IV contrast showing long segment marked wall thickening involving the sigmoid colon and rectum with innumerable mural calcifications. Panel D: MRI pelvis with and without contrast showing the rectosigmoid colon with diffuse T2 hyperintensity and diffuse wall thickening measuring up to 1.0 cm with numerous punctate T1 and T2 hypointense foci consistent with calcifications as seen on CT. A large multiloculated cystic lesion in the left scrotum also noted.
Disclosures: Michael Wagner indicated no relevant financial relationships. Rinad Tabbalat indicated no relevant financial relationships. Nicolas Cal indicated no relevant financial relationships.
Michael Wagner, DO, Rinad Tabbalat, MD, Nicolas Cal, DO. P0216 - Diffuse Cavernous Hemangioma of the Rectum Presenting as Lower Gastrointestinal Bleeding, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.