Mid-GI bleeding of Obscure Cause due to a Cavernous Lymphangioma

Experienced teaching points

Clinical Pearls

Cavernous lymphangiomas are rare, benign intra-abdominal tumors that can present in the small bowel, causing obscure gastrointestinal hemorrhage (melena), anemia, or small bowel obstruction.
Endoscopically, small bowel lymphangiomas can mimic neuroendocrine tumors, appearing as yellowish, polypoid lesions often with a central depression.
While endoscopic therapies (APC, sclerotherapy, EMR) exist for palliation or poor surgical candidates, the ideal curative treatment for a small bowel cavernous lymphangioma is complete segmental surgical resection, guided by prior endoscopic tattooing.

Honorary Professor, Universidad de La República, Montevideo, Uruguay

Visiting Professor, Faculty of Medicine, University of Belgrade, Serbia

Case presentation:

A 32-year-old patient presented with melena and drop in hemoglobin (9 gr/dl). During double balloon enteroscopy a 3 cm yellowish, polypoid lesion with a depressed center was found in the proximal jejunum.

An India Ink tattoo mark was placed to facilitate its recognition during subsequent operative segmental small bowel resection.

Discussion:

Cavernous lymphangiomas are uncommon benign tumors found intra-abdominally, close to the mesentery or in the small bowel.

Small bowel lymphangiomas can cause gross or occult (obscure) gastrointestinal hemorrhage, anemia, abdominal pain, and/or small bowel obstruction. Endoscopists should be aware of this rare tumor and its ileus due to endoscopic features. Cavernous lymphangiomas may endoscopically mimic neuroendocrine tumors. The ideal treatment is complete resection, as incomplete excision may result in recurrence. There are reports on endoscopic therapy using argon plasma coagulation, injection of sclerosants and endoscopic resection. However, those endoscopic options should be mainly used in small lesions, for palliative purposes or in circumstances when a surgical intervention is not feasible.

About the author

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

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