S3575 Case of Iron Deficiency Anemia Secondary to a Pyogenic Granuloma

Abstract

Introduction: Pyogenic granulomas (PG) are lesions in the skin or mucosa composed of vasodilative granulation tissue. Although commonly found in the oral cavity, they are rare throughout the rest of the gastrointestinal (GI) tract. Gastrointestinal PGs typically present as insidious microcytic anemia, which can be severe. We present a case of a patient with iron deficiency anemia secondary to pyogenic granulomas. Case Description/Methods: A 75-year-old Caucasian female referred to the hospital for evaluation for coronary artery bypass graft. Medical history was significant for coronary artery disease, microcytic anemia, tobacco use. On workup, she was found to have iron deficiency anemia with labs showing a hemoglobin of 8.5 g/dL and mean corpuscular volume of 78.3 fL. Her baseline hemoglobin was 12 g/dL last known 5 years before. Iron studies showed low iron at 24 ug/dL and low transferrin saturation of 7%. She denied any hematemesis, melena, or hematochezia. Digital rectal exam demonstrated soft, brown stool. Diet at that time was unchanged from baseline. No other sources of non-GI bleed were identified. Further endoscopic work-up was obtained. Colonoscopy and video pill capsule were unmarkable. Esophagogastroduodenoscopy revealed three large, gastric polypoid lesions that were consistent with visual findings of pyogenic granulomas (Figure). Biopsy revealed an entirely fibrin composition and inflammatory cells with granulation tissue and a strip of reactive foveolar epithelium. Patient was treated conservatively with iron supplementation. Discussion: Pyogenic granulomas are a benign polypoid form of capillary hemangiomas. Initially, it was thought that PGs were caused by infection, but they are most likely multifactorial, including mucosal irritation resulting in reactive processes. Endoscopically, these lesions are commonly erythematous, pedunculated polyps. They are typically described as having a smooth, but visibly ulcerated, surface that can be friable or oozing blood. Further, visual aspects of PG include the underlying vasculature causing dark red to fresh sanguine appearance. Histologically, PGs are lobular-patterned hemangiomas with capillary vessels. Similar to this case, granulation tissue and a single layer of endothelial cells may also be present. Conservative management includes supporting blood loss with iron supplementation. If unresponsive, endoscopic management includes resection with a snare polypectomy, endoscopic mucosal resection, band ligation, or heat application.Figure 1.: Semi-pedunculated polyps (arrows) with hyper vascular appearance. No obvious stigmata of bleeding.