ELECTRONIC GASTRO CURBSIDE CONSULT

An Unusual Case of Lower Gastrointestinal Hemorrhage

Shanshan Xiong, Sinan Lin, and Ren Mao

Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China

Question: A 53-year-old woman, who was in good health, presented with hematochezia for more than 20 days. Examination
was unremarkable, with stable vital signs. Laboratory tests revealed a hemoglobin of 78 g/L (normal 120–160 g/L), and the
rest of the laboratory tests were normal. Colonoscopy revealed multiple masses with a cobblestone appearance, obvious
mucosal congestion, and edema in the junction of sigmoid and rectum (Figure A). Colonic biopsy precipitated active
bleeding that required various measures to stop bleeding. Ice-cold saline solution and 8% norepinephrine (8 mg norepi-
nephrine in 100 mL saline solution) was used to rinse the bleeding site repeatedly and to constrict the vessels, but failed to
stop the bleeding. Titanium clip was then used to clamp the vessels, but blood still exudated. Lauromacrogol was injected to
stop the bleeding eventually (Figure A). She recovered following fluid resuscitation, acid suppression and somatostatin

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therapy. Contrast-enhanced computed tomography (CT) of the abdomen and pelvis is shown in Figures B–E. Three days
later, she developed massive hematochezia with a hemoglobin level of 45 g/L. Owing to effective fluid resuscitation and
blood transfusion, her blood pressure was relatively stable.
What is the most likely cause for lower gastrointestinal hemorrhage in this patient?
See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro
Curbside Consult.
Correspondence
Address correspondence to: Ren Mao, Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou,
510080, People’s Republic of China. e-mail: maor5@mail.sysu.edu.cn.

Acknowledgments
We thank Yan Li for providing the histologic images, Xuehua Li for providing the beautiful radiologic images and writing assistance, and Longyuan Zhou for
providing the writing assistance. We acknowledge the support of Department of Radiology.
Conflicts of interest
The authors disclose no conflicts.

© 2023 by the AGA Institute.

0016-5085/$36.00
https://doi.org/10.1053/j.gastro.2023.02.039

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Answer to: Image 6: Cirsoid Aneurysm

Establishing the Diagnosis

In this case, cobblestone appearance and obvious mucosal congestion (Figure A) made us suspect inflammatory bowel
disease (IBD). However, bleeding following biopsy indicated other possibilities. We next performed CT to get some clue.
Also, a CT scan could help to assess the extent of the lesions. The axial CT plain scan image (Figure B) suggested irregular
thickening and local luminal narrowing of the colonic walls in the left upper abdomen. These colonic lesions showed bead-
like and tortuous tubular enhancement in the arterial phase (Figure C), and their density continued to enhance in the portal
phase (Figure D). On the coronal portal phase image (Figure E), multiple nodular soft tissue-density lesions, which showed
similar enhancement degree as that of adjacent large vessels, were observed around the hilar of liver, abdominal aorta,
inferior vena cava, pancreas, and pelvic cavity; in addition, more extensive intestinal lesions (ie, transverse colon,
descending colon, and sigmoid) were observed. These signs did not support IBD, but indicated extensive cirsoid aneurysm
of the mesentery, retroperitoneum, and colon. Finally, we checked the histology of the biopsy samples (Figure F), which
showed vascular proliferation in the submucosa of the intestinal wall (black arrows). Some vascular lumina were incon-
spicuous (green arrowhead), whereas others contained red blood cells (blue arrowhead), suggesting cirsoid aneurysm.

Review
Cirsoid aneurysm is an arterio-venous malformation with unknown etiology. Cirsoid aneurysms of the stomach and
jejunum have been reported to cause gastrointestinal hemorrhage,1,2 whereas cirsoid aneurysms in the colon are rarely
described. CT angiography is a valuable diagnostic tool, and treatment options depend on the lesions.3 In the present case,
the lesions were extensive and surgery was contraindicated. Interventional embolization proved to be a good option. In
addition, biopsy needs to be performed cautiously, especially for those with obscure gastrointestinal bleeding.

Patient Outcome
The patient underwent emergency angiography, which revealed extravasation of contrast in the junction of sigmoid and
rectum, and embolization of the superior rectal artery was performed (Figure G). She had no further active bleeding after
the embolization. During follow-up, the patient was relatively stable. CT angiography was performed 5 years later. The 3-
dimensional image revealed the extensive cirsoid aneurysm (Figure H), which was consistent with the previous CT findings.
She was suggested to have a regular visit and seek a doctor immediately if melena or abdominal discomfort occurs.
Keywords: Lower Gastrointestinal Bleeding; Cirsoid Aneurysm; Interventional Embolization.

References
1. Eidus LB, Rasuli P, Manion D, et al. Caliber-persistent artery of the stomach (Dieulafoy’s vascular malformation).
Gastroenterology 1990;99:1507–1510.
2. Vetto JT, Richman PS, Kariger K, et al. Cirsoid aneurysms of the jejunum. An unrecognized cause of massive gastroin-
testinal bleeding. Arch Surg 1989;124:1460–1462.
3. ElKiran YM, Abdelgawwad MS, Abdelmaksoud MA, et al. Surgical management of cirsoid aneurysms of the scalp: ten
years’ experience. World Neurosurg 2021;150:e756–e764.

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