S2093 Painless Voluminous Rectal Bleeding: It’s Not Always a “Tic”: A Case of a Recto-Sigmoid Hemangioma

Abstract

Introduction: Hemangiomas are known as benign vascular tumors and may present as multiple or solitary lesions. Very few cases of colonic hemangiomas have been reported in literature. We present a case of rectal bleeding leading to a finding of recto-sigmoid hemangioma. Case Description/Methods: A 31-year-old female with no past medical history presented to the ED with complaints of bright red blood per rectum (BRBPR). She admitted to having 4 days of blood clots associated with bowel movements, in addition to diffuse lower abdominal pain which has occurred intermittently and progressively worsened for the past 2 years. In Cuba, she was told she had a rectal tumor which was “inoperable”. Lab work on admission was significant for iron deficiency anemia. CT of the abdomen and pelvis with oral and IV contrast revealed findings consistent with active gastrointestinal (GI) bleed in the ascending colon, as well as a 2.5 cm pelvic mass. However, an IR arteriogram revealed a large segment of angiodysplasia in the ascending colon but no evidence of active GI bleed. Transvaginal ultrasound ruled out an adnexal mass. Sigmoidoscopy revealed a large recto-sigmoid mass suspicious for an hemangioma as well as surrounding vascular ectasias. Carefully taken biopsies revealed a benign rectal hemangioma. Ultimately, the patient was stabilized and discharged, with follow-up outpatient with surgical oncology due to the extent of her disease (Figure 1). Discussion: Colonic hemangiomas are extremely rare benign vascular lesions of the GI tract. Often located in the recto-sigmoid, they may be discovered during workup for recurrent painless rectal bleed and rarely presenting as life-threatening bleeding. Large cavernous hemangiomas may be associated with Kasabach-Merritt syndrome, hemolytic anemia, thrombosis and bowel ischemia. Studies reveal that it may take on average up to 19 years before a proper diagnosis is established. There are few reported cases of local invasion to surrounding structures such as bladder and uterus. Despite being incidentally found in colonoscopy, insufflation may flatten these lesions which may be also misinterpreted as proctitis. Imaging studies such as MRI, CT and rectal EUS are helpful in determining the diagnosis. Sclerotherapy, angiographic embolization and ligation of mesenteric vessels may be attempted for small lesions. Surgical resection, if possible, is generally the treatment of choice for more extensive lesions. Due to its mimicking presentation of common GI diseases, hemangiomas risk being overlooked.Figure 1.: Extensive recto-sigmoid hemangioma with associated vascular ectasias.