Cavernous Hemangioma of the Colon

Abstract

Purpose: Colonic haemangioma are rare, non-malignant vascular lesions that arise from submucosal vascular plexus, because of embryonic sequestration of mesodermal tissue. Main types are Capillary, Cavernous, and mixed. 70% of colonic haemangioma are Cavernous, may occur as part of multisystem or diffuse gastrointestinal angiomata. Most common site is rectosigmoid. Case Report: 34 years old male presented with longstanding, intermittent complain of pain and bright red blood per rectum that occurs with defecation. Physical examination was significant for LlQ pain, tenderness. Laboratory testing revealed Hemoglobin: 8 and HCT: 29%. During period of 2002 to 2005, multiple colonoscopies were done which showed normal colonic mucosa with slight edema, mild inflammation, minimal architectural disorientation & prominent lymphoid aggregates. Multiple colonic biopsies were taken, all biopsy reports didn't show any abnormality, 1st step IBD marker was detected & he was treated for IBD with Asacol, Prednisone, abdominal cort enema, Rowasa Enema, Imuran but it could not control bleeding. Patient was referred to surgeon, underwent rectal mucosal scrapping which led to diagnosis of Giant rectal haemangioma. The patient subsequently underwent left hemicolectomy with coloanal anastomosis. 1 year later, the patient again came with rectal bleed. Sigmoidoscopy was done & distal rectal mucosa was fulgurated using 5% formalin order to minimise superficial bleed by promoting fibrosis between the mucosa and venous plexuses of haemangioma. Rectum was irrigated with NS to dissolve formalin. Then he had hematuria. Cystoscopy showed Giant Hemengiomatous Vessels. CT Angiogram showed giant IVC, multiple dilated veins throughout abdomen and Bilateral PE that was treated with IV heparin that was changed to Coumadin. 1 year later, he again came for hematuria and RUQ pain. CT scan showed clot in right renal pelvis that was treated with with IV heparin which was changed to Lovenox. Discussion: The haemangioma can present as anemia, hemetochazia, and even massive hemmorhage. Classic endoscopic findings are soft dilated easily collapsible submucosal masses which may be deep wine to plum. The classic endoscopic finding may be absent. Here we have a case which did not had any classical colonoscopic finding so it was misdiagnosed as IBD. Biopsy of the leisions should be performed with caution because massive bleeding can occur. Complete surgical excision of the leisions with a spincter saving procedure is the treatment of choice in symptomatic cases. In this case it was really difficult to anticoagulate the patient when he had pulmonary embolism cause it may make patient to bleed from the carvenous hemangioma.