- Email: [email protected]
An Unusual Cause of Obscure Gastrointestinal Bleeding
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58
An Unusual Cause of Obscure Gastrointestinal Bleeding Q1
Ko-Chin Chen1 and Hsu-Heng Yen2,3 1
Department of Pathology, 2Department of Gastroenterology, and 3General Education Center, Chienkuo Technology University Changhua, Taiwan
Question: A 55year-old man without any remarkable medical history was referred to our hospital for obscure gastrointestinal bleeding. For the past 1 month the patient had been experiencing intermittent episodes of passing tarry stools, which required blood transfusion. Upper endoscopy and colonoscopy performed twice revealed negative findings. Furthermore, abdominal computed tomography scanning revealed no significant intraabdominal lesions. The patient denied using nonsteroidal anti-inflammatory drugs or Chinese herbal drugs and had no fever or weight loss. Laboratory analysis revealed normal liver and renal functions. The white blood cell count was well within the normal range; however, the patient had mild anemia (hemoglobin, 6.4/dL; mean corpuscular volume, 99.8). A capsule endoscopy was performed (Figure A, B; Video 1). What were the findings of capsule endoscopy? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
© 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.06.010
Gastroenterology 2016;-:e1–e2 DIS 5.4.0 DTD YGAST60516 proof 5 October 2016 5:52 pm ce
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172
Answer to: Image 2: A Mucosal Epithelioid Angiomatous Nodule in the Jejunum
The capsule endoscopy revealed a submucosal tumor of the jejunum without any mucosal color change (Figure A). A small blood-coated ulceration was found on the tumor (Figure B; Video 1). At surgery, a 1.5-cm tumor with cleft-like ulceration was found in the distal jejunum (Figure C). Microscopically, the vascular lesion showed an exophytic polypoid configuration with mucosal ulceration and comprised slightly atypical epithelioid cells growing in solid and vasoformative patterns (Figure D; stain: hematoxylin and eosin; original magnification: 20). The endothelial cells stained with CD31, with preserved pericytic cells (Figure E; immunohistochemical stain for smooth muscle actin; original magnification: 100). Consequently, a mucosal epithelioid angiomatous nodule (EAN) was diagnosed. EAN is a rare, benign vascular tumor and was first described by Brenn and Fletcher in 20041 as a new clinicopathologic entity of epithelioid vascular tumor. EAN is pathologically similar to 2 other vascular lesions2: epithelioid hemangioma and pyogenic granuloma. Unlike EAN, epithelioid hemangioma is typically multilobulated and has large vessels. Pyogenic granuloma,3 also called lobular capillary hemangioma, is composed of capillary-sized vessels with inflamed and edematous stroma. EAN is characterized by a well-circumscribed and solid proliferation of endothelial cells with prominent epithelioid features.1 It appears as a solitary, reddish, growing nodular lesion of the skin or nasal cavity. Only <50 cases of EAN have been reported so far in the literature.1,2 The present case is the first reported case of EAN in the gastrointestinal tract, with obscure gastrointestinal bleeding. The pathogenesis of EAN is unknown; owing to its brief duration of development, a reactive disorder has been suggested as the underlying cause. Local excision is the treatment of choice for EAN of the skin or nasal cavity. The patient in the present case did not experience recurrent bleeding in the 6 months after tumor excision.
References 1. 2. 3.
Brenn T, Fletcher CD. Cutaneous epithelioid angiomatous nodule: a distinct lesion in the morphologic spectrum of epithelioid vascular tumors. Am J Dermatopathol 2004;26:14–21. Wong WK, Lim DH, Ong CW. Epithelioid angiomatous nodule of the nasal cavity: Report of 2 cases. Auris Nasus Larynx 2015;42:341–344. Misawa S, Sakamoto H, Kurogochi A, et al. Rare cause of severe anemia due to pyogenic granuloma in the jejunum. BMC Gastroenterol 2015;15:126.
e2 DIS 5.4.0 DTD YGAST60516 proof 5 October 2016 5:52 pm ce
173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228
An Unusual Cause of Obscure Gastrointestinal Bleeding Q1
Ko-Chin Chen1 and Hsu-Heng Yen2,3 1
Department of Pathology, 2Department of Gastroenterology, and 3General Education Center, Chienkuo Technology University Changhua, Taiwan
Question: A 55year-old man without any remarkable medical history was referred to our hospital for obscure gastrointestinal bleeding. For the past 1 month the patient had been experiencing intermittent episodes of passing tarry stools, which required blood transfusion. Upper endoscopy and colonoscopy performed twice revealed negative findings. Furthermore, abdominal computed tomography scanning revealed no significant intraabdominal lesions. The patient denied using nonsteroidal anti-inflammatory drugs or Chinese herbal drugs and had no fever or weight loss. Laboratory analysis revealed normal liver and renal functions. The white blood cell count was well within the normal range; however, the patient had mild anemia (hemoglobin, 6.4/dL; mean corpuscular volume, 99.8). A capsule endoscopy was performed (Figure A, B; Video 1). What were the findings of capsule endoscopy? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
© 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.06.010
Gastroenterology 2016;-:e1–e2 DIS 5.4.0 DTD YGAST60516 proof 5 October 2016 5:52 pm ce
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172
Answer to: Image 2: A Mucosal Epithelioid Angiomatous Nodule in the Jejunum
The capsule endoscopy revealed a submucosal tumor of the jejunum without any mucosal color change (Figure A). A small blood-coated ulceration was found on the tumor (Figure B; Video 1). At surgery, a 1.5-cm tumor with cleft-like ulceration was found in the distal jejunum (Figure C). Microscopically, the vascular lesion showed an exophytic polypoid configuration with mucosal ulceration and comprised slightly atypical epithelioid cells growing in solid and vasoformative patterns (Figure D; stain: hematoxylin and eosin; original magnification: 20). The endothelial cells stained with CD31, with preserved pericytic cells (Figure E; immunohistochemical stain for smooth muscle actin; original magnification: 100). Consequently, a mucosal epithelioid angiomatous nodule (EAN) was diagnosed. EAN is a rare, benign vascular tumor and was first described by Brenn and Fletcher in 20041 as a new clinicopathologic entity of epithelioid vascular tumor. EAN is pathologically similar to 2 other vascular lesions2: epithelioid hemangioma and pyogenic granuloma. Unlike EAN, epithelioid hemangioma is typically multilobulated and has large vessels. Pyogenic granuloma,3 also called lobular capillary hemangioma, is composed of capillary-sized vessels with inflamed and edematous stroma. EAN is characterized by a well-circumscribed and solid proliferation of endothelial cells with prominent epithelioid features.1 It appears as a solitary, reddish, growing nodular lesion of the skin or nasal cavity. Only <50 cases of EAN have been reported so far in the literature.1,2 The present case is the first reported case of EAN in the gastrointestinal tract, with obscure gastrointestinal bleeding. The pathogenesis of EAN is unknown; owing to its brief duration of development, a reactive disorder has been suggested as the underlying cause. Local excision is the treatment of choice for EAN of the skin or nasal cavity. The patient in the present case did not experience recurrent bleeding in the 6 months after tumor excision.
References 1. 2. 3.
Brenn T, Fletcher CD. Cutaneous epithelioid angiomatous nodule: a distinct lesion in the morphologic spectrum of epithelioid vascular tumors. Am J Dermatopathol 2004;26:14–21. Wong WK, Lim DH, Ong CW. Epithelioid angiomatous nodule of the nasal cavity: Report of 2 cases. Auris Nasus Larynx 2015;42:341–344. Misawa S, Sakamoto H, Kurogochi A, et al. Rare cause of severe anemia due to pyogenic granuloma in the jejunum. BMC Gastroenterol 2015;15:126.
e2 DIS 5.4.0 DTD YGAST60516 proof 5 October 2016 5:52 pm ce
173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228