1779 An Unexpected Cause of Iron Deficiency Anemia

Abstract

INTRODUCTION: A 74-year-old Hispanic male with hypertension and depression was evaluated due to microcytic anemia associated with fatigue, generalized weakness and intermittent palpitations. Patient denied dysphagia, unintentional weight loss, abdominal pain or rectal bleeding. Laboratories were remarkable for Hgb 11 g/dL, MCV 79.8 fL, ferritin 20 ng/mL , iron level 36 μg/dL, TIBC of 293 μg/dL and a transferrin saturation of 12%. Patient underwent a colonoscopy for evaluation of iron deficiency anemia, which failed to reveal any pathology. CASE DESCRIPTION/METHODS: Esophagogastroduodenal endoscopy (EGD) was performed. EGD revealed, upon retrieval of the scope, a pedunculated polypoid lesion near the gastroesophageal junction. The lesion was removed using hot snare technique. Histologic examination revealed, “Erosive squamous mucosa with necro-inflammatory debris (consistent with an ulcer) associated with lobular mucosal vascular proliferation and capillary structures lined with endothelium with flat nuclei.” Infectious immunostaining for viral entities, including Cytomegalovirus and Herpes Simplex Virus were negative. Gomori Methenamine-Silver and Periodic Acid Schiff taining for fungi were also negative. The histological features and immunostaining profile were consistent with a lobular capillary hemangioma (pyogenic granuloma). Six months after the therapeutic endoscopy, the patient was asymptomatic and with adequate hemoglobin levels. DISCUSSION: Lobular capillary hemangiomas are benign vascular lesions that are commonly found in the skin or oral mucosa. The pathophysiology of lobular capillary hemangiomas remains a mystery. These lesions are rarely found in the gastrointestinal tract. Due to the propensity of these vascular lesions to bleed into the GI tract, severe anemia can develop, especially if not identified and/or treated correctly. In our patient there was no stigmata of recent bleeding, but here was evidence of iron deficiency anemia. Mucosal resection is curative and recurrence is rare. This case report describes a rare benign vascular condition, known as a lobular capillary hemangioma, which, by its location at the distal esophagus, was causing iron deficiency anemia through obscure GI bleeding. It demonstrates that it is imperative to evaluate the esophagus carefully during retrieval, since they may be missed.