Rare But Curious Finding

1
Rare But Curious Finding

• a rapid review of a few vascular lesions of the
  GI tract.

2
Presentation

• 73 year old male
• To endoscopy suite for colonoscopy
• No complaints
• PMHx 15mm polyp resected from sigmoid 5/2000
  which was discovered to have adenocarcinoma in
  situ. Endoscopic surveillance with flex sig
  4/2001 presents for 3 year colonoscopy. Has
  history of coronary artery disease requiring CABG
  1998, DM, HTN, hypercholesterolemia.
• Meds Pravachol, ASA, metformin, insulin, HCTZ,
  metoprolol.

3
Unrevealing review of systems

• No change in bowel habits, no weight loss, no
  abdominal pain.
• No previous history of GI blood loss.
• Has history of normochromic, normocytic anemia
  (hemoglobin 11-12).

4
Family/Social History

• No family history of GI malignancy or any other
  notable GI abnormality
• Retired mason.
• Lives with wife. Denies tobacco use, occasional
  alcohol.

5
Physical Exam

• Vitals normal
• Oropharynx moist without lesion, good dentition
• Lungs clear, sternotomy scar noted
• Heart regular
• Abdomen soft without surgical stigmata
• Rectal exam with external skin tag, otherwise
  normal

6
Endoscopic findings
7
Endoscopic findings
8
Endoscopic findings
9
Endoscopic findings
10
Endoscopic findings
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Endoscopic findings
12
Endoscopic findings
13
The Attending Requests the Differential Diagnosis

• Angiodysplasia
• Blue Rubber Nevi
• Hemangiomas
• Kaposi Sarcoma
• Random Varicosities

14
Vascular Lesions of the Gastrointestinal Tract

• Aneurysms of the aorta and its branches
• Blue rubber bleb nevus
• Congenital arteriovenous malformation
• Dieulafoys lesion
• Glomus tumor
• Hemangioma
• Hemangiomatosis
• Hemangiopericytoma
• Hemangiosarcoma
• Hemorrhoids
• Kaposis sarcoma
• Vascular ectasia (angiodysplasia)
• Capillary phlebectasia

15
Representative photos of angiodysplasia
16
Representative photos of angiodysplasia
17
Syndromic Angiodysplasia?Hereditary Hemorrhagic
Telangectasia
18
Pathogenesis of Angiodysplasia
19
Blue rubber nevi, serosal visualization
20
Blue Rubber Nevi, epithelial surface
21
Blue Rubber Bleb Syndrome

• Cutaneous vascular nevi associated with
  intestinal lesions and gastrointestinal bleeding
• Familial history is infrequent, although a few
  cases of autosomal dominant transmission have
  been reported
• The lesions are distinctive blue and raised,
  varying from 0.1 to 5.0 cm, and leaving a
  characteristic wrinkled sac when the contained
  blood is emptied by direct pressure
• Lesions may be single or innumerable and are
  usually found on the trunk, extremities, and face
  but not on mucous membranes they are most common
  in the small intestine.
• The lesions are cavernous hemangiomas composed of
  clusters of dilated capillary spaces lined by
  cuboidal or flattened endothelium with connective
  tissue stroma.
• Resection of the involved segment of bowel is
  recommended for recurrent hemorrhage
• Endoscopic laser coagulation may be dangerous
  because these lesions may involve the full
  thickness of the bowel wall.

22
Hemangiomas
23
Kaposi Sarcoma
24
Kaposi Sarcoma

• Thought to be related to HHV-8 (with HIV
  co-infection)
• Pathogenesis complex involving cytokines,
  integrins, and altered apoptosis and cell cycle
  controls
• Histopathology characterized by proliferation of
  abnormal vascular structures with proliferation
  within the tumor of vascular structures and
  slits, often lined by abnormally large,
  malignant-appearing endothelial cells and
  extravasation of erythrocytes.

25
Phlebectasias, medical literature

• Markedly dilated and tortuous submucosal veins,
  unassociated with portal hypertension.
• These veins have a normal endothelium and scant
  connective tissue stroma.
• Usually occur in clusters generally classified
  as multiple, small hemangiomas, but this
  classification is somewhat controversial
• Can also occur at the base of the tongue, where
  they are called caviar varices and in the
  genitalia, where they are called Fordyce lesions
• At colonoscopy, they are dark bluish-gray, small,
  soft, compressible, and blanch with
  pressureOccasionally cause GI bleeding.
• Cappell MS - Med Clin North Am - 01-Nov-2002
  86(6) 1253-88

26
Phlebectasias, GI literature

• Venous ectasias, also called phlebectasias,
  differ from angiodysplasias and varices
  pathologically and clinically.
• These lesions consist of dilated submucosal veins
  usually with thin overlying mucosa. These venous
  varicosities have a normal endothelial lining,
  are nonneoplastic, and are not associated with
  liver disease.
• Endoscopically, they appear as multiple, bluish
  red nodules and occur predominantly in the rectum
  and the esophagus.
• Small bowel lesions have been described.
• They are an uncommon cause of bleeding and are
  usually asymptomatic.
• Lewis BS - Gastroenterol Clin North Am -
  01-Mar-2000 29(1) 67-95

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• Given the asymptomatic nature of the lesions, the
  patients history (absence of HIV) and the
  appearance of the lesions
• The final diagnosis is phlebectasia, and no
  further evaluation or treatment is indicated.