Approach to upper digestive hemorrhage with diagnosis of cavernous lymphangioma

LETTER TO THE EDITOR

Approach to upper digestive hemorrhage with diagnosis of cavernous lymphangioma

Carlos Rafael Lima Monção

Santa Casa de Montes Claros, Minas Geral, MG, Brazil

Correspondence

INTRODUCTION

Lymphangioma consists of lymph vessels-like structures. Are considered benign tumors of such vessels. Presents three histological types: cystic cavernous and simple and can occur in different regions of the body such as head and neck, mesentery and gastrointestinal tract^1,5,6. This publication aims to expose a rare case of cavernous lymphangioma, diagnosed after extensive workup for upper gastrointestinal bleeding.

CASE REPORT

Men 68 years, hypertensive patient, with a history of ischemic stroke two years ago. He sought medical attention with severe microcytic and hypochromic anemia and several episodes of melena. Underwet to endoscopy evidencing on the second duodenal portion granulous inflammatory process, friability and presence of blood residues, mild distal esophagitis and mucosal pallor. Biopsy revealed a diagnosis of chronic nonspecific duodenitis. He was submitted two more endoscopies with biopsies that showed the same endoscopic and histological changes without adding any other data.

Proceeding with colonoscopy, mucosa presented with color, brightness and transparency usual, but with the presence of blackened secretion in the cecum. Image examinations found in abdominal ultrasonography mesogastric inferiorly in the pancreas region two nodules above the aorta measuring about 3.7 x 1.9 and 2.0 x 1.5 cm (Figure 1).

In total abdominal CT contrast, it was noted thickening of the third portion of the duodenum and proximal jejunum with massive retroperitoneal lymph node, and several lymph nodes diffusely distributed (Figure 2).

The intestinal transit showed irregularities in mucosal, thickening at the third portion of the duodenum and proximal jejunum of unknown etiology. Was further performed abdominal aortography and selective arteriography of the superior and inferior mesenteric artery, not being evidenced by angiography signs of active bleeding.

The treatment was performed by laparotomy with inventory of abdominal cavity, where it was found vegetating lesion infiltrating the proximal jejunum and mesentery. Histology showed portions of tissue with blood and lymphatic vascular spaces lined by endothelium with fibrofatty stroma sometimes forming cysts; the final diagnosis was cavernous linfoangioma

DISCUSSION

Linfagiomas are benign lesions that are usually congenital malformations, especially in regions of the head and neck, but can affect various topographies and organs⁴. Therefore, symptoms and complications depend on the site and size. Three histologic subtypes are presented separately for the most part, however there may be different classes within a single tumor.

The diagnosis may be suspected by ultrasonography, computed tomography and magnetic resonance imaging of the affected segment, and do not present any characteristic in these exams⁷. Confirmation must be made by histopathologic or immunohistochemistry².

A surgical excision of the lesion and adjacent tissues consists the better treatment⁵. A partial resection is associated with high recurrence rate, reaching to 50% at two years3.

REFERENCES

• 1. Christison-Lagay ER, Fishman SJ. Vascular Anormalies. Surg Clin N Am 2006; 86: 393-425.
• 2. Glasgow SC, Birnbaum EH, Lowney JK, et al. Retrorectal Tumors: A diagnostic and Therapeutic Chalenge. Dis Colon Rectum 2005; 48: 1581-87.
• 3. Hebra A, Brown M, McGeehin K, Ross A - Mesenteric, omental, and retroperitoneal cysts in children: the clinical study of 22 marries. South Med J, 1993; 86: 173-6.
• 4. Legienh GM, Heran MKS. Classification, Diagnosis and Interventional Radiologic Management of Vascular Malformations. Orthop Clin N Am 2006; 37: 435 -74.
• 5. Perrot M, Rostan O, Morel P, et al - Abdominal lynphangioma in adults and children. Br J Surg, 1998; 2:385-95.
• 6. Schefter RP, Olsen KD, Gaffey TA. Cervical lymphangioma in the adult. Otolaryngol Head Neck Surg 1985;93:65-9.
• 7. Vara-Thorbeck C, Méndez RT, Hidalgo RH, et al Laparoscopy resection of a giant mesenteric cystic lymphangioma. Eur J Surg 1997; 163: 395-6.

Publication Dates

• Publication in this collection
  16 May 2013
• Date of issue
  Mar 2013