SOLITARY ILEAL LYMPHANGIOMA, A RARE CAUSE OF OBSCURE INTESTINAL BLEEDING REQUIRING TRANSFUSION SUCCESSFULLY TREATED WITH LAPAROSCOPIC RESECTION

Justin D Sargent, DO¹, Hassan Masoudpoor, MD¹, Jeffrey J Kraft, MD², John Davis, MD¹. ¹Hackensack Meridian Health Palisades, ²Hackensack University Medical Center

INTRODUCTION: Small bowel lymphangioma is a rare benign vascular system tumor that mostly presents in children as head, neck or axillary region masses. Generally they are asymptomatic and don’t require treatment, unless complications arise, such as bleeding or obstruction. Small bowel lymphangiomas are very rare in adults and intestinal bleeding secondary to a solitary ileal lymphangioma presenting with severe anemia requiring transfusion are rarely reported.

CASE DESCRIPTION: 54 year old male presented to ED with sudden onset of lower abdominal pain without remarkable past medical history. A small urinary tract stone with hydronephrosis was identified. Incidentally on CT an area of mural thickening of a short segment of small bowel in the left lower quadrant was noted. Mild asymptomatic anemia was found, and patient was recommended outpatient endoscopic follow-up with analgesics for the renal calculi.

The patient was lost to follow up due to insurance reasons and returned to our hospital after three months with recurrent and severe anemia requiring blood transfusion and intravenous iron treatment. He denied any episodes of melena, hematochezia, chest pain, nausea and vomiting. The patient only complained of the mild exertional SOB, but was compensating by decreasing activity at home. Clinical examination revealed marked conjunctival pallor. No masses were palpated on rectal or abdominal examination. On admission a microcytic anemia with hemoglobin of 4.3 gr/dL was noted. CT was performed showing segmental circumferencial thickening of a loop of ileum without perienteric stranding and lymphadenopathies. Remainder of the large and small bowel including terminal ileum was identified normal. The patient received a transfusion prior to upper and lower endoscopy.

Esophagogastroduodenoscopy was normal except mild gastritis. Colonsocopy didn’t reveal active bleeding or abnormalities in the colon. No bleeding was noted in the terminal ileum. Subsequently, he underwent technetium labeled red blood cell scan and no focus of active bleeding identified.

Given the CT findings and endoscopic workup, the patient underwent diagnostic laparoscopy and intraoperatively an 8 cm section of the mid-ileum was found distended distinctly from the surrounding bowel and it was resected with the feeding mesentery with a 5cm margin. Histologic examination showed multiple endothelium lined cystic spaces and associated smooth muscle fibers consistent with a lymphangiomatous lesion.

DISCUSSION: Lymphangiomas in the jejunum or ileum are extremely rare and surgery can be necessary when bleeding is not controlled by gastroenteroscopy. To avoid recurrence, laparoscopic segmental bowel resection is an optimal approach.