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PYOGENIC GRANULOMA: AN UNUSUAL CAUSE OF MASSIVE GASTROENTESTINAL BLEEDING FROM THE SMALL BOWEL
DC Moffatt, H Singh
INTRODUCTION: Pyogenic granuloma (PG) is an extremely rare vascular and inflammatory lesion that occurs most commonly in the epidermis and oral cavity. PG is a non-malignant inflammatory capillary hemangioma. On several occasions, PG has been described in the colon, in the distal esophagus and only once previously in the small intestine. Here we report the first case of PG presenting with a massive gastrointestinal hemorrhage and briefly review the literature involving treatment and prognosis of patients with PG.
CASE REVIEW: We report the case of a 78 year old male with three years of chronic transfusion-dependant microcytic anemia thought to be secondary to chronic myelofibrosis with microcytosis. Increasing transfusion requirements and declining ferritin levels (18ug/l) precipitated thorough GI work up for a possible occult bleed. EGD and ileocolonoscopy yielded no findings. A nuclear medicine tagged red blood cell scan was performed showing a possible bleed in the RUQ, most likely in the small bowel.
One month later, the patient presented with pre-syncope, hypotension and large volume melena, requiring hospitalization and transfusion of 8 units of packed RBCs. Push enteroscopy revealed a 2-3cm red-blue polypoid lesion into the proximal jejenum and biopsies were taken. Ensuing hemodynamic instability forced urgent laparotomy and removal of 50cm of jejunum which achieved hemostasis. Over the next 6 months, the patient’s chronic anemia resolved. Pathology revealed this lesion to be a pyogenic granuloma. Time has proven it responsible for both his chronic anemia and acute upper GI bleed.
CONCLUSION: PG is a rare cause of chronic upper and lower GI bleeding and iron deficiency anemia. To date, 14 cases have been reported in the literature. Only two have occurred in non-Asian patients, only one has occurred in the small bowel and this is the first case of PG presenting with a massive GI bleed. Both surgical (N=10) and endoscopic removal (N= 4) appear safe and effective.