Hidden Bowel Mass in a Patient with Iron Deficiency Anemia

Abstract

Purpose: A 72-year-old woman presented to our clinic because of symptomatic iron deficiency anemia. She denied any recent episode of overt bleeding from anywhere or gastrointestinal symptoms. Subsequently she received 2 units of packed red blood cells as hemoglobin continued dropping to the level of 7.0 g/dL. Colonoscopy was finally performed 6 months later as the patient declined the procedure repeatedly. During the colonoscopy procedure, she was found to have bloody material in the cecum without obvious lesions initially (Figure A). The cecum was then deflated and inflated several occasions. During the process, a moderate size sessile lesion arising from terminal ileum was seen invaginating intermittently into cecum. The lesion displayed several erosions on its surface, which explained the presence of bloody material in the cecum (Figure B). Histopathology showed well-differentiated endocrine neoplasm (carcinoid) with mucosal ulcer and granulation tissue reaction. Carcinoid tumors of terminal ileum or ileocecal valve were usually diagnosed by radiological imaging, laparotomy and ileal intubation during colonoscopy. Ileal intubation during colonoscopy has been advocated to be performed to all instances of unexplained lower gastrointestinal bleeding. Our case is the first, to our knowledge, of a moderate size carcinoid tumor of terminal ileum with intermittent appearance to cecum. Ileal intubation as part of colonoscopy is a topic of great debate and a study has demonstrated that performing routine ileal intubation in patients with anemia has little diagnostic value. However, this case highlights the benefit of ileal intubation when evaluating patients with iron deficiency anemia, especially in the presence of bloody material in the cecum.Figure AFigure B