Solitary pyogenic granuloma of the small bowel as the cause of obscure gastrointestinal bleeding

 

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Pyogenic granuloma is rare in the gastrointestinal tract and mostly occurs on the skin and in the oral cavity [1]. This type of lesion usually bleeds and is responsible for chronic anemia and gastrointestinal bleeding of unknown origin [2] [3] [4] [5]. Here we report on a case of pyogenic granuloma in the jejunum diagnosed by capsule endoscopy and treated by snare polypectomy using double-balloon enteroscopy.

A 55-year-old white man with no previous medical history presented with an 8-month history of anemia and a positive fecal occult blood test. His only complaint was weakness. He denied melena or hematochezia. Laboratory data were as follows: hemoglobin level, 9.9 g/dL (normal range, 12.8 – 16.5 g/dL); hematocrit level, 31 % (normal range, 37 % – 52 %); red blood cell count, 371 × 10⁴/mm³ (normal, > 420 × 10⁴/mm³); and platelet count, 253 000/mm³ (normal, > 140 000/mm³). During this period, he underwent upper gastrointestinal endoscopy, which revealed no potential bleeding lesion, and colonoscopy, which revealed sigmoid diverticulum and no signs of bleeding. Computed tomography scan of the abdomen was normal. Capsule endoscopy revealed a small hyperemic sessile polypoid lesion in the jejunum without bleeding ([Fig. 1]).

Fig. 1 Capsule endoscopy: hyperemic small-bowel polyp (pyogenic granuloma).

The patient underwent double-balloon endoscopy, which confirmed the findings of capsule endoscopy ([Fig. 2]) and permitted endoscopic diathermy snare polypectomy with no complications.

Fig. 2 Hyperemic small-bowel sessile polyp confirmed by double-balloon enteroscopy.

The resected specimen was 4 mm in diameter. Histologic findings revealed proliferation and lobular arrangement of capillary vessels, swelling of the endothelial cells within edematous stroma, and mixed inflammatory cell infiltration ([Fig. 3]); these findings were compatible with pyogenic granuloma.

Fig. 3  Histologic findings of the pyogenic granuloma (hematoxylin and eosin, × 100) b Histologic findings of the pyogenic granuloma (hematoxylin and eosin, × 400).

There was no recurrence of gastrointestinal bleeding 10 months after the endoscopic resection.

In conclusion, pyogenic granulomas of the small bowel should be considered as rare lesions that cause obscure gastrointestinal bleeding. With the advent of double-balloon enteroscopy, these lesions can be safely treated by endoscopic means.

Endoscopy_UCTN_Code_CCL_1AC_2AD

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R. Kuga
MD

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