Small Bowel Lymphangioma Research Articles

Preoperative Diagnosis of Small Bowel Lymphangioma in an Adult

Preoperative Diagnosis of Small Bowel Lymphangioma in an Adult

S3043 A Push to Find the Answer: A Rare Case of Jejunal Lymphangioma

Introduction: Lymphangioma arises from malformations of lymphatic vessels.Approximately 90% of cases present within the first two years of life with 95% occurring in the head, neck, and axilla.It is rarely found in adults, and small bowel lymphangioma represent less than 1% of cases.We present a rare case of a woman with melena and chronic anemia who was found to have a bleeding jejunal lymphangioma. Case Description/Methods: A 60-year-old female with coronary disease, atrial fibrillation, and chronic anemia presented with symptomatic acute on chronic anemia with a hemoglobin of 5.7gm/dL, MCV 67, and ferritin 3 ng/mL.The patient was evaluated for melena one month ago at an outside hospital with a normal esophagogastroduodenoscopy and colonoscopy.At discharge, anticoagulation for atrial fibrillation was discontinued given recurrent gastrointestinal bleeds. At our institution, the gastroenterology service pursued a second look push enteroscopy to evaluate a suspected small bowel source.This revealed three jejunal folds with circumferential, protruding, white plaque-like lymphangiectasia with areas of ulceration and oozing.There was no target to intervene on, so the area was biopsied and tattooed.Pathology was consistent with lymphangioma. Given multiple admissions for gastrointestinal bleeding and requirement of anticoagulation, surgery was consulted for resection.The resection confirmed a 7 cm, full thickness, lymphangioma with arteriovenous malformation of the jejunum which was negative for neoplasm. The patient recovered and was discharged without further bleeding. Discussion: Lymphangiomas are caused by a proliferation of multiple, thin-walled lymphatic space believed to be from a congenital lymphatic malformation, but it is theorized to be associated with inflammation, abdominal surgery, abdominal trauma or obstruction of developed lymphatic vessels.Although small bowel lymphangioma is a benign condition and normally clinically silent, it can present with symptoms such as abdominal pain, nausea, vomiting, and weight loss.Complications associated with lymphangiomas include bleeding, protein-losing gastroenteropathy, volvulus, and intussusception.According to Kida, 15 cases of bleeding small bowel lymphangioma have been reported from 1967 to 2012.While small bowel lymphangiomas are rare, it should be considered in a patient with clinically significant bleeding without an identifiable source.Our case allowed us to demonstrate the unique endoscopic appearance and complications associated with this rare entity.Figure 1.: Image 1: Push enteroscopy revealing three jejunal folds with white-plague lesions consistent with lymphangiomas. Image 2: Lymphangioma with ulceration and active bleeding. Image 3: (A) Lymphangioma of the small intestine. The vascular channels are dilated, lined by inconspicuous endothelium, and contain lymphatic fluid and blood cells. H&E, 50x. (B) Lymphangioma of the small intestine. D2-40 immunostain highlights the lymphatics component. H&E, 20x.

Gastrointestinal: Small bowel lymphangioma diagnosed by single‐balloon enteroscopy

A 46-year-old woman was referred with 3 months of episodic abdominal pain, melena, fatigue and shortness of breath. The patient's fecal occult blood was positive, and the complete blood count revealed severe anemia suggestive of gastrointestinal bleeding. Blood transfusion was performed to maintain her hemoglobin around 90 g/L. Following admission, the patient was investigated with esophagogastroduodenoscopy (EGD) and colonoscopy, but the location of bleeding was not identified. Video capsule endoscopy (CE) showed red blood in the jejunum, but the etiological factor remained unknown. The patient was futher referred for a single-balloon enteroscopy (SBE) investigation. Based on the location of the lesion on CE, antegrade SBE was performed with the patient under general anesthesia. A circumferential submucosal lesion with thickened and yellowish-white mucosal folds was identified in the proximal part of the jejunum. Many bleeding points could be seen on the surface of the lesion (Figure 1). The lesion appeared consistent with a typical lymphangioma. Dilated lymphatic vessels were evident in endoscopic biopsy specimen, which confirmed the lesion to be small-bowel lymphangioma (Figure 2). The patient was then referred for surgical resection of the lesion. The tumor was found at 15 cm distal to the ligament of Treitz and was resected successfully. The surgical specimen was of a soft, yellow-white lesion and was measured at 60 × 50 mm. The cut surface contained tiny multicystic spaces with milky fluid. Histological examination revealed a localized area of numerous and variable-sized dilated lymphatic channels in the mucosa and submucosa. The final diagnosis was simple lymphangioma with bleeding into the lymphatic vessels. The patient's melena resolved immediately after surgery and did not recur. Lymphangiomas are usually found in childhood and adult cases are rare. The etiology of lymphangiomas is probably a primary malformation of the lymphatic system. Histologically, lymphangiomas are classified into three types: simple, cavernous or cystic. Small-bowel lymphangioma is a benign tumor of the lymphatic system, and it is very rare. It is reported that Lymphangiomas comprise only 3% of benign small bowel tumors. Lymphangioma is usually discovered incidentally during examination or operation for an unrelated complaint. However, they are rarely reported as the cause of significant GI bleeding or acute abdominal pain. Single-balloon enteroscopy (SBE) has established itself as an effective tool in the diagnosis and management of small bowel diseases since its availability in 2006. It is reported that SBE system is easier to perform and may provide higher quality images superior than double-balloon enteroscopy. This is the first case report of small-bowel lymphangioma diagnosed through single-balloon enteroscopy. Surgery is the treatment for small bowel lymphangiomas, surgeons usually aim for complete removal of the tumor with surrounding organs of potential invasion, because there is a possibility of recurrence and invasion to surrounding organs. Contributed by

A pedunculated polyp-shaped small-bowel lymphangioma causing gastrointestinal bleeding and treated by double-balloon enteroscopy

We report a rare case of a small-bowel lymphangioma causing massive gastrointestinal (GI) bleeding that we successfully diagnosed and treated using double-balloon enteroscopy (DBE). An 81-year-old woman suffering from repeated GI bleeding of unknown origin underwent a capsule endoscopy at a previous hospital. She was suspected of having bleeding from the jejunum, and was referred to our department for diagnosis and treatment. An oral DBE revealed a 20 mm × 10 mm, regularly surfaced, white to yellowish, elongated, pedunculated jejunal polyp with small erosions at 10 cm distal to the ligament of Treiz. Since no other source of bleeding was identified by endoscopy in the deep jejunum, an endoscopic polypectomy (EP) was performed for this lesion. A subsequent histopathological examination of the resected polyp showed clusters of lymphatic vessels with marked cystic dilatation in the submucosa and the deep layer of the lamina propria mucosae. These characteristics are consistent with the typical features of small-bowel lymphangioma with erosions. Although clipping hemostasis was performed during EP, re-bleeding occurred. Finally, a complete hemostasis was achieved by performing an additional argon plasma coagulation.

Double-balloon enteroscopy in the diagnosis and treatment of hemorrhage from small-bowel lymphangioma: a case report

Double-balloon enteroscopy in the diagnosis and treatment of hemorrhage from small-bowel lymphangioma: a case report

Small Bowel Lymphangioma

Purpose: Mesentric lymphangioma is a rare benign cystic tumor of lymphatics of the bowel. It is usually found in the first decade of life and has a female predominance in adults. It differs from other mesenteric and retroperitoneal cysts, as it is proliferative and invasive in nature. It is usually asymptomatic in adults and found on surgery or autopsy. It rarely presents as occult GI bleed and iron deficiency anemia. We present such a patient in whom capsule endoscopy was diagnostic. Methods: Our patient is a 36 year old female who presented with fatigue, shortness of breath, occassional diffuse abdominal pain, melena and dizziness for 6 months. She denied any nausea, vomiting, hematochezia, NSAID use or family h/o cancer. Labs revealed Hb of 3.7, Hct 12.5, MCV 60.4, Plt 461, WBC 7.2, Iron 2, Ferritin 3, TIBC 367 and positive FOBT x 3. After transfusion of 4 units PRBC, Hb improved to 9.8. Small bowel enteroscopy with biopsies revealed mild antral gastritis, H. pylori negative and normal villous architecture. Colonoscopy was completely normal. Abdominal CT and Small Bowel series showed luminal narrowing and thickening of small bowel loops in left upper quadrant. Patient was given a patency capsule which passed without any complications. Capsule endoscopy revealed a mass like lesion with yellowish – white discoloration with active bleeding in the small bowel. Laparoscopic resection of the lesion showed diffuse dilatation of the mucosal, submucosal and subserosal lymphatics consistent with small bowel lymphangioma. The post operative course was uneventful and patient was discharged. Results: Conclusion: Abdominal lymphangiomas are uncommon benign tumors. The mean age at presentation is 2.2 years with a male predominance. Etiology may be benign proliferation of ectopic lymphatics. 95% of lymphangiomas are found in the neck and axilla and very rarely found in the intestine. Clinical presentation include abdominal pain, distention, fever, and vomiting. There may be features of small bowel obstruction or volvulus. In an Australian study of 416 capsule endoscopies, 27 tumors were identified of which only 1 was a lymphangioma. Plain radiography may demonstrate small-bowel obstruction or noncalcified soft-tissue mass. CT and MRI may show multiloculated fluid-filled masses, thickening of the bowel wall and reveal size of the tumor, characteristics of the cyst wall and location. Capsule endoscopy may lead to earlier detection and treatment and an improved prognosis for patients with these neoplasms. The prognosis of lymphangiomas depends on location and extent of the lesion. Complete resection is the treatment of choice and has an excellent prognosis. The recurrence rate ranges from 0–13.6%. Malignant degeneration to a low-grade sarcoma is rare.

Extracolonic Tumors of the Gastrointestinal Tract Detected Incidentally at Screening CT Colonography

The aim of this article is to report our experience with incidental detection of extracolonic tumors of the gastrointestinal tract identified prospectively at screening CT colonography. A total of 2014 patients (1097 females, 917 males; mean age, 56.9 years) underwent primary CT colonography evaluation at our institution over an 18-month period. Following cathartic preparation and colonic distention, supine and prone multidetector CT scans were obtained with thin-collimation low-dose technique without intravenous contrast. We reviewed our database for lesions of the extracolonic gastrointestinal tract that were detected during the prospective reading. Focal extracolonic gastrointestinal tract lesions were prospectively detected in 10 (0.5 percent) of 2014 patients (8 females; 2 males; mean age, 58.5 years). All patients were asymptomatic. Tumor locations included ileum (n = 3), stomach (n = 3), jejunum (n = 2), and appendix (n = 2). Mean tumor size was 2.2 (range, 0.8-3.4) cm. Lesions in eight patients were subsequently confirmed by conventional or capsule endoscopy and/or by intravenous contrast-enhanced CT. Seven lesions were surgically excised and one was removed at endoscopy; two patients with lipomas did not undergo further evaluation or treatment. Final diagnoses were benign in all cases and included lipoma (n = 3), small-bowel hamartoma (n = 2), appendiceal mucinous cystadenoma (n = 2), gastric leiomyoma (n = 1), small-bowel lymphangioma (n = 1), and gastric fundic gland polyp (n = 1). Incidental extracolonic tumors of the gastrointestinal tract detected at screening CT colonography were all asymptomatic and benign but often prompted more invasive workup. Although the incidence of these tumors was relatively low, widespread population screening with CT colonography would result in new surgical referrals for these findings.

Cystic Lymphangioma of the Small Bowel in a Woman at 15 Weeks?? Gestation

Lymphangiomas are uncommon benign tumors, usually encountered early in childhood. Here is described the case of a pregnant woman at 15 weeks' gestation with a symptomatic ileal small bowel lymphangioma that was approached laparoscopically. A limited number of laparoscopically managed cases of abdominal lymphangiomas have been reported. This is the first reported laparoscopically assisted resection of a small bowel cystic lymphangioma during pregnancy.