Abbreviations: TP: Total Protein; Alb: Albumin; AST: Aspartate Aminotransferase; ALT: Alanine Aminotransferase; LDH: Lactate Dehydrogenase; BUN: Blood Urea Nitrogen; Cre: Creatinine; UIBC: Unsaturated Iron Binding Capacity; WBC: White Blood Cell; RBC: Red Blood Cell; Hb: Hemoglobin; Hct: Hematocrit: RET; Reticulocyte; Plt: Platelet

Introduction

In Japan, Obscure Gastrointestinal Bleeding (OGIB) is defined as persistent or recurrent bleeding with no apparent source on Esophagogastroduodenoscopy (EGD) and Colonoscopy (CS) [1]. OGIB accounts for approximately 5–10% of all cases of gastrointestinal bleeding, and 75% of these cases involve the small bowel [1-3]. Pyogenic Granulomas (PGs) are inflammatory vascular tumors commonly occurring on the oral mucosa or skin and characterized by a propensity to bleed [4]. PGs rarely occur in the gastrointestinal tract, especially in the small intestine, and are a rare cause of gastrointestinal bleeding. In this report, we describe a case of as OGIB diagnosed as PG by Capsule Endoscopy (CE) and Double Balloon Endoscopy (DBE).

Case Presentation

The patient was an 84-year-old woman. She was receiving treatment for arteriosclerosis obliterans and diabetes and was taking two antithrombotic medications. She underwent Esophagogastroduodenoscopy (EGD) and Colonoscopy (CS) two months before, due to abdominal pain and diarrhea. No abnormalities were detected in the examinations at that time, and the patient was under observation. However, the progression of anemia was observed during the course of the follow-up, and the patient visited the department of gastroenterology for a second examination. She was not aware of melena. EGD and CS were performed; however, no obvious source of bleeding was found. Laboratory data at the time of admission to our hospital are shown in (Table 1).

Table 1: Descriptive lab data at the initial visit.

Contrast-enhanced Computed Tomography (CT) did not reveal an obvious source. We suspected OGIB and performed CE, revealing a polyp-like finding in the jejunum with adherent blood (Figure 1). This was thought to be the cause of the anemia and the source of the bleeding; therefore, an oral DBE was performed for close examination. A submucosal raised tumor-like lesion with a blood clot was found in the upper jejunum, though not large in size (approximately 10 mm in diameter) (Figure 2). The lesion was judged to be difficult to resect endoscopically; it was marked with ink dots and surgical resection was planned. A partial resection of the small intestine was performed (Figure 3) and the patient was discharged after 15 days without major complications. Histological examination revealed a single layer of proliferating capillaries covered with endothelial cells, inflammatory cells in the interstitium, and pathologically diagnosed PG (Figure 4). The postoperative course was uneventful, and there was no subsequent relapse of symptoms.

Figure 1: A lesion (5 mm mass) was discovered using capsule endoscopy; its head was erythematous and some parts were hemorrhaging.

Figure 2: Double-balloon endoscopy findings. There was no bleeding; however, the entire mass was erythematous and submucosal tumor-like in morphology.