S2557 An Unusual Cause of Obscure Gastrointestinal Bleeding

Abstract

Introduction: Obscure gastrointestinal bleeding is bleeding of unknown origin, that persists or recurs, after a negative initial or primary endoscopy. It accounts for approximately 5% of all cases of gastrointestinal bleeding and is usually due to a lesion in the small bowel. We present a case of rare cause of obscure gastrointestinal bleeding. Case Description/Methods: 68 year old male, was admitted with history of passing black coloured stools since last 2 weeks. History of weightloss was present. History of squamous cell carcinoma vocal cord in the past and he underwent radiation therapy. Blood investigations showed anemia. Endoscopy showed antral erosions. Colonoscopy revealed caecal angiodysplasia and was treated with Argon plasma coagulation. In view of persistent melena, patient underwent CT angiography, which revealed bowel wall thickening with cavitation and focal bowel dilatation involving the jejunum (Fig 1). Spiral enteroscopy revealed an ulceroproliferative neoplasm about 4 x 3 cm, involving more than half the circumference of jejunum (Fig 2). He was discharged after stabilisation. Two weeks later, patient was admitted with abdominal pain. CT abdomen revealed dilated jejunal loops with bowel wall thickening and eccentric cavitation. A small loculated collection of size 3.6x1.8cm with a tiny air foci was seen along with minimal free fluid (Fig 3). On laparotomy, a perforated tumor in proximal jejunum, 25 cm away from DJ flexure, was identified. He underwent resection and end to end anastomosis. On histopathology, sections from jejunum showed transmural infiltration by a tumour arranged in sheets. The tumour cells were polygonal to epithelioid, with heterogeneously clumped chromatin. Interspersed proliferated blood vessels were noted. The neoplastic cells show diffuse strong positivity for Pan CK , Vimentin and patchy positivity for CK 7,CD31. CD34 highlighted the vessels. They were negative for p40, CDX2, CK20, CK 5/6, WT1, HMB45, SMA, CD117 and DOG 1. Histopathology was suggestive of a poorly differentiated sarcoma, with IHC suggestive of epitheliod angiosarcoma. Discussion: Primary angiosarcoma of small intestine is very rare. Epithelioid angiosarcomas are rare tumors, accounting for less than 1%. Angiosarcoma of small bowel may be associated with previous radiation treatment, chemotherapy, and chemical toxin exposure, specifically polyvinyl chloride. Angiosarcoma of small intestine can be considered as a rare cause in a patient who presents with obscure gastrointestinal bleed.Figure 1.: Bowel wall thickening with cavitation and focal bowel dilatation involving the jejunum, Fig 2: Spiral enteroscopy , Fig 3: Dilated jejunal loops with bowel wall thickening and eccentric cavitation, Fig 4/5 Histopathology , Fig 6: Immunohistochemistry.