Pyogenic Granuloma: A Rare Cause of Obscure Gastrointestinal Bleeding

Abstract

Pyogenic granuloma is a lobular capillary hemangioma that occurs mostly on the skin, and occasionally on the mucosal surface of the oral cavity, but very rarely in the gastrointestinal tract. We report a case of a 63-year-old man who suffered from iron deficiency anemia with multiple syncopal episodes and intermittent melenic stools for the past 1 year. Multiple studies at various centers including esophagogastroduodenoscopies (EGDs), push enteroscopies, colonoscopies, bleeding scintigraphies, and abdominal CT scans during this time period could not reveal the bleeding source. He had not received medical treatment except for oral iron. The patient was transferred to our University hospital for further assessment after he presented to an outside facility with presycope, moderate volume melena, and a hemoglobin of 4.0 g/dl. Initially, a colonoscopy was done which only showed a scant amount of dark blood in the terminal ileum. Next, a video capsule endoscopy revealed a bleeding focus in the jejunum without a distinct etiology. Afterwards, antegrade and retrograde single balloon enteroscopies were planned to locate the source. During retrograde single balloon enteroscopy, a 15 mm pedunculated polypoid mass, with active bleeding, was found in the small intestine 90 cm away from the ileocecal valve (Image 1 and Image 2). The bleeding was controlled with epinephrine injection and hemoclip placement. The following day, surgical resection of the small bowel segment was performed. The histological features revealed a capillary hemangioma with a pyogenic granuloma pattern (Image 3). Shortly after resection, the patient's anemia improved and he had no further bleeding episodes. The small bowel is the source of gastrointestinal bleeding in 2% to 10% of all bleeding episodes. Vascular tumors of the small bowel are very rare, accounting for only 7% to 10% of all benign tumors of the small bowel. Pyogenic granulomas of the small bowel are difficult to diagnose, as they are usually inaccessible via conventional endoscopic techniques. This patient underwent a total of 8 endoscopic and radiologic procedures prior to finally visualizing this rare source of bleeding. This case demonstrates the challenges in the diagnosis and management of obscure GI bleeding. One should be aware of the rare causes of obscure GI bleeding such as pyogenic granuloma and utilize the appropriate diagnostic modalities such as capsule endoscopy and balloon-assisted enteroscopy in finding the source.Figure 1Figure 2Figure 3