An Unusual Cause of Obscure Gastrointestinal Bleed: Ileal Inflammatory Polyp

Abstract

A 58 year old male presented to his primary care physician's office with a complaint of increased fatigue with exercise over the preceding nine months. His blood work at the initial visit was notable for microcytic anemia with a hemoglobin of 8.2 g/dL, hematocrit 28.4% and MCV 65.8 fL. On further investigation, he was also found to be iron deficient. The patient had no history of anemia prior to this visit. His colonoscopy from one year prior had been unremarkable. An EGD was performed and was notable for esophagitis grade B and duodenitis on biopsy, but no other significant findings. A video capsule endoscopy revealed an area of polypoid, ulcerated mucosa in the distal small bowel. This study was followed by a CT enterography notable for a 4.5 centimeter ovoid intraluminal lesion in the distal ileum (Figure 1). A double-balloon retrograde enteroscopy performed at an outside hospital was unremarkable. The patient underwent a diagnostic laparoscopy with findings of an ileal mass proximal to the tattoo-mark of the previous retrograde double-balloon enteroscopy. The ileal segment was resected and a macroscopic examination was notable for a 3 x 2 x 1.6 cm polypoid mass with intraluminal prolapse (Figure 2). Microscopic review was notable for markedly inflamed small intestinal mucosa with edema and enlargement of intestinal villi. The inflammatory infiltrate consisted of lymphocytes, plasma cells and neutrophils with muscle wall in the middle indicating prolapse and attachment of the muscularis propria. There was no evidence of atypia or Crohn's disease. The mass was diagnosed as an inflammatory polyp of the ileum. The patient recovered without complication and his anemia resolved.1992_A Figure 1. 4.5 cm ovoid intraluminal lesion in distal ileum on CT enterography (arrows)1992_B Figure 2. Surgical specimen of ileal resection containing 3 x 2 x 1.6 cm inflammatory polypSmall bowel lesions account for approximately 5-10% of all gastrointestinal bleeding1. The most common etiologies in individuals 41-65 years of age consist of vascular anomalies, small intestinal tumors and non-specific enteritis1-3. Of these etiologies, tumors account for 5-10%4. Inflammatory polyps are nondysplastic lesions consisting of inflamed and regenerating mucosa above the mucosal surface4. These polyps are commonly found in the colon where they can be associated mainly with inflammatory bowel disease and infection5. However, small bowel inflammatory polyps are less commonly reported. When located in the small bowel, inflammatory polyps are associated with abdominal pain, iron deficiency anemia and intussusception6-9.