Review

Case reports are essential to the clinician's daily practice because they frequently cover unusual cases. After reading the case report by Quiros and colleagues,¹ it will be easier to confirm the diagnosis of granuloma pyogenicum in a patient.

Pyogenic granulomas represent the acquisition of vasodilative granulation tissue in the skin or mucosa. They are extremely rare in the alimentary tract, other than in the oral cavity. The vascular nature of gastrointestinal lesions leads to chronic blood loss, resulting in iron deficiency anemia, a well-known warning sign of gastrointestinal tumors. Due to their unusual appearance, gastrointestinal lesions can be easily misdiagnosed and mistreated, either as gastrointestinal cancer treated with extensive surgery or as hyperplastic polypoid lesions, which would indicate no further treatment. Therefore, an understanding of how to diagnose and treat this condition is important for gastroenterologists to know.

Quiros and colleagues report a rare case of pyogenic granuloma in the stomach of a 67-year-old woman with severe iron deficiency anemia.¹ The main difference between their case and the case of pyogenic granuloma that we reported² is the appearance of the lesion. The lesion described by Quiros and colleagues appeared to be polypoid, whereas we found a sessile form. Quite understandably, a polypoid lesion could easily be misdiagnosed as a hyperplastic polypoid, whereas our lesion would more likely be misdiagnosed as colonic cancer, if the biopsy result were inconclusive. Surgical intervention was obvious in our case regardless of the diagnosis reached; in the case reported by Quiros and colleagues, a crucial decision was taken to remove the polypoid lesion despite its harmless appearance. Before removing the polypoid lesion, an endosonographic investigation was conducted, which revealed no signs of infiltration of the stomach wall and which was followed by a complete mucosectomy. Although endosonographic investigation of polypoid lesions was fruitful in this case, it is not wholeheartedly recommended in the literature for several reasons: first, because a high-resolution endoscopy or examination for the lifting sign before snare polypectomy is equally accurate,³ and second, because predicting postpolypectomy bleeding is difficult.⁴ Nevertheless, endosonography is frequently used to predict the infiltrative nature of the lesion, as in a case of pyogenic granuloma in the esophagus reported by Hoekstra and coworkers.⁵

In almost all published case reports, a definitive diagnosis was made after resection of the lesion. It is very important to discuss the issue from the pathologic point of view, as Quiros and colleagues did, because of an often-misleading diagnosis based on endoscopic biopsy. The complete removal of the lesion—either by endoscopic snare resection when the lesion is small or by surgery where there is a large or infiltrative lesion—is the treatment of choice. The authors are correct to point out that the main factor in avoiding a recurrence of the lesion is complete resection.

The case report is well described by Quiros and colleagues, and their review of the current literature is nearly complete. However, in addition to the case report from Hoekstra and coworkers⁵ discussed above, another interesting case report regarding two children with colonic pyogena granulomas should be highlighted.⁶ The unusual aspect of this case report is the treatment of the pyogenic granuloma in the case of an 18-month-old girl. This patient had undergone orthotopic liver transplantation for biliary atresia at the age of 7 months. Abdominal computed tomography scan revealed bowel wall thickening in the left mid-abdomen with localized fatty proliferation in the mesentery. Colonoscopy showed an area of circumferential black necrosis at the splenic flexure. Histologic examination revealed a pyogenic granuloma. In this case, a combination of antibiotic and antifungal therapy was administered, and the lesion had almost disappeared after 2 weeks. This is especially unusual because all other published cases of pyogena granulomas have involved removal by surgery or snare polypectomy. Two other case reports have been published regarding pyogenic granuloma in the non–English-language literature, one in the stomach⁷ and one in the rectum.⁸

In summary, the article provides an easy-to-recall example of pyogenic granuloma, with good illustrations and details of the endoscopic and pathologic findings. The treatment options are also described concisely and accurately. Hopefully, after reading the case report, clinicians will be familiarized with this condition and avoid unnecessary diagnostic diversions.