Capillary hemangioma in the ileum: Obscure small-bowel bleeding in an elderly person

Dear Editor,

Capillary hemangioma (CH) is a benign vascular proliferation comprising small, capillary-sized blood vessels, usually occurring in the skin and soft tissue of children, but seldom occurs in the elderly. Further, hemangioma of the small intestine is not common, but may occur in the ileum segment of children. Its pathogenesis may be linked to congenital anomalies originating from residual embryonic angiogenic cells (1).

Here, we present a case of a 73-year-old man with a CH in his ileum. The patient suffered from light headedness and episodes of melena. He also felt feeble with a weight loss of 5 kg over the past 6 months. His abdomen was soft and nontender, with no palpable masses, as revealed by physical examination. In addition to iron deficiency anemia, fecal occult blood test was positive, and other laboratory test values were in the normal range. Gastroscopy and colonoscopy revealed gastritis and colonic polyps with no bleeding lesions.

Capsule endoscopy confirmed proliferative foci and active bleeding in the ileum. Accordingly, the patient received a double balloon enteroscopy, in which a polypoid bulge was found in the ileum 1.5 m proximal to the ileocecal valve. The bulge was wide at its base (approximately 10×20 mm in size) with superficial congestion, erosion, granular hyperplasia, and bleeding. Subsequently, a surgical exploration was performed, and the ileal lesion was resected via laparoscopic excision. The lesion was then divided into sections and stained with hematoxylin and eosin for immunohistochemical analysis (CD31 and CD34) (2). The stained sections were observed under 100× magnification to reveal lesioned epithelium. The cellular lesions had a well-formed lobular architecture under low-power microscopy and contained plump endothelial cells lining the vascular spaces with inconspicuous lumens and feeding vessels.

Hemangiomas are classified according to their clinical appearance and the vessels involved, such as capillary, cavernous, and mixed vessels (3). CH consists of small, capillary-sized blood vessels. Since CH is rarely detected in the small intestine, only few cases have been reported.

Although CH is generally considered to be benign, it can be a cause of chronic gastrointestinal bleeding and/or obstruction (4). The most significant clinical symptom of CH is hemorrhage, which tends to be slow and insidious; such long-term intermittent bleeding may lead to iron deficiency anemia. Although CH can be effectively treated with surgical resection, it is so rare in the ileum of the elderly that most physicians do not consider it during diagnosis (3). In addition to this, it is rather difficult to identify CH with routine examinations such as computed tomography, magnetic resonance imaging, and colonoscopy. Therefore, capsule endoscopy and double balloon enteroscopy may represent the most important tools for discovering lesions of the jejunoileum. CH can be effectively diagnosed via clinical appearance, capsule endoscopy, double balloon enteroscopy, and pathology.

In conclusion, we report a case of solitary intestinal CH causing long-term intermittent bleeding. Although these lesions are rare, a better understanding of these lesions will aid physicians in making definitive diagnostic and treatment plans (5).