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ORIGINAL CONTRIBUTION
Year : 1997  |  Volume : 51  |  Issue : 3  |  Page : 97-99
 

Solitary cavernous haemangioma of the jejunum with intra-abdominal bleeding - Case report


Department of Pathology and General Surgery, Kasturba Medical College and Hospitals Mangalore-575 001., India

Correspondence Address:
Radha R Pai
Department of Pathology and General Surgery, Kasturba Medical College and Hospitals Mangalore-575 001.
India
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PMID: 9355717

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How to cite this article:
Pai RR, Lobo FD, Kini H, Ballal R, Kini A, Raghuveer C V. Solitary cavernous haemangioma of the jejunum with intra-abdominal bleeding - Case report. Indian J Med Sci 1997;51:97-9

How to cite this URL:
Pai RR, Lobo FD, Kini H, Ballal R, Kini A, Raghuveer C V. Solitary cavernous haemangioma of the jejunum with intra-abdominal bleeding - Case report. Indian J Med Sci [serial online] 1997 [cited 2014 Sep 30];51:97-9. Available from: http://www.indianjmedsci.org/text.asp?1997/51/3/97/11524


Haemangiomas are rare lesions in the gastrointestinal tract. The overall incidence is about 1:14000 patients, and those of small bowel form 3 to 4% of all tumours of the small bowel and 0.3% of all tu­mours of the gastrointestinal tract. [1] The diagnosis is most often an incidental finding either at lapa­rotomy or at autopsy. A preopera­tive diagnosis of haemangioma is rarely made since the symptoms produced are highly variable and difficult to interpret. Herein we describe a very interesting case of solitary cavernous haemangioma of the jejunum in a 38 year old male, presenting with clinical fea­tures of amoebic colitis. A mass lesion was detected on ultrasono­graphy. At laparotomy the vascu­lar lesion was identified with intra­peritoneal rupture and haematoma formation. Diagnosis was revealed only on histopathological exami­nation.


 ¤ Case Report Top


A 38 year old male was admitted with history of pain in abdomen and loose stools since one month. Pain was dull aching and localised to the right iliac fossa. Blood and mucus were present in the stools. There was no history of vomiting. A diffe­rential diagnosis of amoebic colitis and ulcerative colitis were con­sidered.

On examination pallor was pre­sent, pulse was 100/minute and blood pressure 130/80 mmHg. Per abdominal examination revealed tenderness in the right iliac fossa with mild guarding. On ausculta­tion sluggish bowel sounds were heard. Rectum was empty on per rectal examination. CVS and RS were within normal limits. Plain X-ray abdomen was normal. Abdo­minal ultrasonography showed fea­tures of peritonitis with pelvic col­lection and a mass lesion in the right iliac fossa. Exploratory lapa­rotomy was performed and the toneal cavity with oedematous findings were : blood in the peri­small intestine, a haematoma con­tained by omentum and a haemor­rhagic perforating growth in the jejunum 20 cms from the duodeno­jejunal flexure. Liver was normal. Blood was sucked out, haematoma evacuated and the omentum was divided and ligated. Jejunum with the tumour was resected and end-­to-end anastomosis performed. Postoperative recovery was un­eventful.

Grossly the specimen consisted of resected small intestine mea­suring 20 cmm in length. Sero­sal aspect showed an irregular haemorrhagic nodular area mea­suring 5 cm in diameter which on cut surface was seen extending into the submucosa giving a poly­poidal appearance on the mucosal aspect. The immediate adjacent mucosa appeared normal [Figure 1]. Microscopically sections through ,the leson showed large area of hae­morrhage expanding the submu­cosa with perforation through the muscular layer. The overlying mucosa was intact except for oedema and haemorrhage. Large covernous blood filled spaces lined by flattened cells were seen in the submucosa at the periphery of the lesion. A diagnosis of cavernous haemangioma with intra­peritoneal rupture was made.


 ¤ Discussion Top


On review of literature the va­rious symptom-complexes pro­duced by small intestinal haemor­rhage occult or massive, small bowel obstruction (partial or com­plete) and inflammation of the lesion simulating acute appendi­citis. If the lesion is large and poly­poidal intussusception may occur. [2] Intraperitoneal rupture has been described as an unusual complica­tion. [3] The commonest symptom however is that of bleeding from the bowel causing anaemia. [2] These different modes of presentation makes a preoperative diagnosis difficult. Three cases of polypoid haemangioma of the small intes­tine were located in the Indian Literature 2 presenting with intus­susception [2],[4] and one with intrac­table malena. [5]

Intestinal haemangioma may be solitary or multiple. [1] If cutaneous haemangiomas are present as in the case of haemangiomatosis the intestinal lesions are usually multiple. Grossly they form a poly­poid mass or a diffuse infiltrating lesion. They are usually soft, red, blue or wine coloured. Rarely the tumour forms a constricting almost circumferential mass. Dumb­bell shaped tumours are describ­ed. [6] Midjejunum is the most com­mon location. [6] In our case he tumour was in the jejunum 20 cms away from the duodenojejunal flexure. Microscopically cavernous haemangioma is the most common followed by capillary and mixed capillary-cavernous haemangioma in equal proportion. [6] Several emphasize that a preoperative diagnosis of intestinal haeman­gioma is never easy. Despite the rarity of this entity, it should be considered in the differential diagnosis of gastrointestinal bleed­ing of unknown origin both in adults and childhood. According to Hansen [2] the diagnosis will be more frequently made if due atten­tion is paid to the following : 1)Presence of haemangioma on the skin and mucous membrane. 2) Presence of phlepboliths on X-ray. 3) The significant association of intussusception with polypoid hae­mangioma. 4) Presence of inden­tations and constrictions in the small intestine in cases of other­wise unexplained gastrointestinal haemorrhage.

In conclusion haemorrhage into the abdominal cavity with haema­toma formation due to the rupture of an intestinal haemangioma is an extremely unusual occurrence worthy of reporting.

 
 ¤ References Top

1.Morson & Dawson's Gastrointesti­nal Pathology 3rd Ed, pp 382-383, London, Blackwell Scientific Publi­cation. 1990.  Back to cited text no. 1      
2.Baruah BD, Naught, Goswami PK. Haernangioma of the ileum with intussusception - Review of the literature and report of a case. Ind J Surg 1958;20:498-503.  Back to cited text no. 2      
3.3 Gastellote Caixal JM, Laengo R, Ledesma L. et al. Intraperitoneal haemorrhage caused by cavernous haemangioma of the small intestine. Rev Esp Enfern Dig 1995;87:155­-157.  Back to cited text no. 3      
4.Manchanda RL, Talwar JR. Poly­poid haemangioma of the jejunum causing intussusception. Ind J Surg 1957;19:274-276.  Back to cited text no. 4      
5.Mampilly J, Nair VJ, Mathai KM. Polypoid haemangioma of the ileum (A case report). Ind J Surg 1981; 43:674-676.  Back to cited text no. 5      
6.Boyle L, Lack EE. Solitary Caver­nous Haemangioma of Small Intes­tine - Case Report and Literature Review. Arch Pathol Lab Med 1993; 117:939-941.  Back to cited text no. 6  [PUBMED]    


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