Selective embolization can effectively alleviate bleeding symptoms in patients with anorectal hemangioma

Abstract

In this manuscript, I comment on the article by Pospisilova et al published in the recent issue of the journal, in which selective embolization was used to treat anorectal hemangioma, a rare disease causing lower gastrointestinal bleeding. Anorectal hemangioma can easily be mistaken; for example, the patient in this case was previously misdiagnosed with ulcerative colitis. Choosing the appropriate tests and understanding the typical manifestations of anorectal hemangioma under colonoscopy, computerized tomography, magnetic resonance imaging and other tests are beneficial for diagnosis. The patient presented with intermittent rectal bleeding despite treatment with azathioprine and mesalazine and required blood transfusions since the degree of rectal bleeding worsened. Selective embolization successfully alleviated the patient’s bleeding symptoms and avoided the need for repeated blood transfusions. Tranexamic acid may be useful, considering that the patient still has bleeding symptoms and requires parenteral iron supplementation.

Key Words: Gastrointestinal hemangioma; Anorectal hemangioma; Treatment; Surgery; Endoscopic therapy; Medication

Core Tip: The incidence rate of anorectal hemangioma is low, and it is easy to misdiagnose. Colonoscopy, computerized tomography, magnetic resonance imaging, and other tests are helpful for diagnosis. The selection and results of examinations are crucial for doctors to make correct medical decisions. After comprehensive examinations and a clear diagnosis, selective embolization can alleviate patients’ symptoms and improve their quality of life.

TO THE EDITOR

Recently, Pospisilova et al[1] reported a case in which selective embolization was used to treat anorectal hemangioma. Hemangiomas occur less frequently in the gastrointestinal tract; gastrointestinal hemangiomas predominantly occur in the small intestine and are characterized by gastrointestinal bleeding[2]. Gastrointestinal hemangiomas can exist alone or in various syndromes, such as blue rubber bleb nevus, Maffuci, and Klippel-Trenaunay-Weber[3]. Therefore, observing whether there are lesions on the skin of the patient’s mouth, head, neck, or perianal area can provide a basis for differential diagnosis. Anorectal hemangioma is characterized mainly by chronic rectal bleeding, which can lead to secondary sideropenic anemia. Owing to misdiagnosis as hemorrhoids or ulcerative colitis, diagnosis and treatment are often delayed[4]. For example, the patient in this case was previously misdiagnosed with ulcerative colitis, and it took 8 years for the patient to receive an accurate diagnosis.

DIAGNOSIS

According to one report, patients with gastrointestinal hemangiomas wait an average of 19 years between initial symptoms and final diagnosis[5]. In this case, a clear diagnosis was obtained through inquiries about chief complaints, a history of present illness, family history and examinations, including colonoscopy, computerized tomography (CT), magnetic resonance imaging (MRI) and serology, which shortened the time from initial symptoms to final diagnosis for this patient. Submucosal venous dilation and engorgement can be observed via colonoscopy. Both CT and MRI can reveal thickened intestinal walls and submucosal lesions. Atypical pelvic phleboliths can be found on CT, and signal voids can be found on MRI[6]. The MRI features of anorectal hemangioma also include low signals on T1-weighted images and high signals on T2-weighted images[7]. These imaging findings are present in the patient in this case, providing a reference for selecting subsequent treatment. In addition to colonoscopy, CT and MRI, Aylward et al[8] suggested that patients with rectal hemangiomas should undergo mesenteric angiography to clarify the vascular supply of the lesion and make accurate clinical decisions. Some researchers believe that the possible presence of multiple thrombi in the supply vessels can lead to a low positive rate on angiography[9]. Further research is needed to determine whether patients with anorectal hemangioma should undergo routine mesenteric angiography.

TREATMENT

The treatment of anorectal hemangioma includes medication, endoscopic therapy, and surgery. When doctors make treatment decisions, it is necessary to consider the size, location, extent of the lesion, transmural involvement, and extracolonic organ involvement. The treatment for patients without overt symptoms consists of observation and follow-up. The need for iron supplementation or blood transfusions can be considered based on the degree of anemia. The patient in this case had to undergo blood transfusions due to intermittent rectal bleeding and symptomatic anemias. Although the patient did not need blood transfusions after selective embolization, he still required parenteral iron therapy. Tranexamic acid may be useful for this purpose. Patients treated with tranexamic acid do not require further blood or iron transfusions for over two years[10]. When the condition permits, anterior rectal resection and coloanal anastomosis with sphincter preservation are preferred for anorectal hemangiomas. Surgical treatment may lead to a high risk of fecal incontinence due to the large size of the lesion; therefore, sclerosing injection is a better choice. Patients who choose sclerosing injection to treat rectal hemangiomas undergo routine mesenteric angiography during surgery. Pai et al[11] reported that patients who choose surgical treatment to cure small intestinal or colorectal hemangiomas can also undergo mesenteric angiography before surgery. Its main purpose is to prevent the omission of lesions during surgery and reduce the recurrence rate of chronic bleeding. Neither drug therapy nor endoscopic therapy can completely remove the lesion; thus, there is a risk of recurrent bleeding. According to the report by Wang et al[9], patients may require frequent blood transfusions due to incomplete lesion resection and persistent or even aggravated rectal bleeding after sclerosing injection. Therefore, regular follow-up is necessary.

CONCLUSION

In general, if a patient has experienced unexplained recurrent rectal bleeding since childhood with significant vascular dilation under colonoscopy, gastrointestinal hemangioma, a rare disease, needs to be considered[12]. Serology tests, gastrointestinal endoscopy, CT, and MRI, can assist in diagnosing and excluding other diseases, such as hemorrhoids and ulcerative colitis. When making medical decisions, it is necessary to consider the size, location, extent, presence of transmural lesions and extraintestinal organ involvement, such as the bladder. Tranexamic acid may be useful for detecting bleeding symptoms. With regular follow-up, selective embolization can alleviate patients’ bleeding symptoms and improve their quality of life.