2038 Jejunal Lymphangioma: A Rare Cause of Gastrointestinal Bleeding

INTRODUCTION: Lymphangioma is a rare benign vascular tumor in adults. The etiology is not clear but is proposed to be from the anomalous development of the lymphatics or inflammation and obstruction of developed lymphatics (1). Although most cases are asymptomatic and thus detected incidentally, non-specific symptoms, including abdominal pain, nausea, vomiting and weight loss may be present (2). Here we present a case of such tumor presenting as obscure overt GI bleed. CASE DESCRIPTION/METHODS: A 76-year-old female with past medical history of DM, ESRD, CHF, AFib presented with SOB and hypotension. Three weeks prior, she had a cardiac arrest during dialysis and was found to be anemic on admission to outside hospital (Hb 5.9). She was diagnosed with PE and anticoagulation was started. This resulted in multiple episodes of melena. She was deemed clinically unstable for EGD/colonoscopy and was discharged (Hb 8.6). A week later, she was again found to be anemic (Hb 5.8) and continued to have multiple episodes of melena. Colonoscopy and EGD were unremarkable and she was eventually discharged again. Her symptoms recurred following discharge and she was hospitalized now with SOB and hypotension (Hb 6.4). She continued to have melena. Diagnostic tagged RBC scan showed possible focus of luminal hemorrhage in small bowel in left abdomen. A capsule endoscopy showed a jejunal mass with active bleeding. Subsequent single balloon enteroscopy revealed a 2.5 cm polypoid mass with active bleeding in the mid-jejunum. Biopsies were taken and hemostasis was achieved with argon plasma laser. Histology revealed this mass to be a lymphangioma. She was discharged with no further bleeding. At 2 months follow up, she still did not have any further bleeding. She elected not to pursue any further management. DISCUSSION: A lymphangioma is a rare benign tumor. For lymphangioma, intestinal tract involvement is very uncommon. GI bleeding, intestinal obstruction, intussusception and protein-losing enteropathy are very rare manifestations(5). Diagnostic tests include barium enema, CT scan and endoscopic evaluation (7-9). Surgical resection may be required to provide definitive diagnosis and treatment. The upper and lower GI endoscopies can sometimes miss the mass, as in our patient. In such cases, capsule endoscopy and push enteroscopy play an important role. In our case, conservative measure was chosen due to the surgical risks of the patient from multiple comorbidities.