Abstracts: CLINICAL VIGNETTES/CASE REPORTS - SMALL INTESTINE/UNCLASSIFIED
Jejunal Leiomyoma as a Cause of Obscure Gastrointestinal Tract Bleeding
Purpose: Introduction lower gastrointestinal bleeding (LGIB) is a common problem in acute care setting. Most are caused by colonic pathology including diverticulosis, angiodysplasia, and colon cancer. Jejunal bleeding is rarely the cause. We present a case of jejunal leiomyoma as the cause of obscure LGIB.
Case presentation: A 48-year-old Asian male presented with a one-day history of hematochezia and dizziness.The bleeding was painless and associated with non-bloody emesis. Physical examination was unremarkable with stable vital sign. His hemoglobin on presentation was 10 g/dL with a nadir of 6.6 g/dL. He received 6 units of pack red cell transfusion in the first 24 hours. The day after admission, patient underwent esophago-gastro-duodenoscopy (EGD) and colonoscopy. EGD showed mild erosive gastritis and duodenitis. Colonoscopy showed non-bleeding hemorrhoid and fresh blood in the colon. He then underwent a radionucleotide bleeding scan, which showed active hemorrhage in the central small bowel, distal sigmoid and proximal rectum. Mesenteric angiography was then performed but did not show any sources of bleeding. Prompting a repeat EGD with push enteroscopy and a repeat colonoscopy was performed and showed mild duodenitis. The colonoscopy demonstrated non-bleeding sigmoid diverticulosis without evidence of active bleeding. Subsequently, the CT enterography was performed and revealed a 2.7-cm homogeneously enhancing hyperdense mass in the wall of the jejunum likely representing a gastrointestinal stromal tumor. The patient underwent exploratory jejunal resection. Pathological examination confirmed the diagnosis of leiomyoma. Immunohistochemical staining demonstrated the tumor cells positivity for smooth muscle actin and desmin and negativity for CD117 and CD34.
Discussion: Jejunal leiomyoma is a rare cause of LGIB bleeding especially with patients over 40 years of age2. Although the true prevalence is unknown, case reports of bleeding jejunal leiomyoma remain rare. Bleeding is the most common clinical manifestation of jejunal leiomyoma. According to previous case reports, angiography seems to be the most sensitive investigation to preoperatively diagnose small bowel leiomyoma. However, in our case, angiography was not able to demonstrate the tumor. To our knowledge, this is the first case report describing a bleeding jejunal leiomyoma with negative angiography. Some studies showed the CT enterography has the higher or similar sensitivity in detecting sources of obscure small bowel bleeding than wireless capsule endoscopy. CT enterography may be the alternative noninvasive study of choice in the algorithm for obscure gastrointestinal bleeding.© The American College of Gastroenterology 2013. All Rights Reserved.