Severe rectal bleeding caused by a small polypoid lobular capillary hemangioma

A 52-year-old man without comorbidities was admitted to our gastroenterology department after he collapsed while on the toilet and noticed passage of bright red blood per rectum. On clinical examination he appeared to be healthy. Only mild abdominal pain was noticed. He was normotensive but with mild tachycardia (111/min). Laboratory analysis was unremarkable except for normocytic anemia (hemoglobin 78g/L). He deniedmedicine consumption. In order to exclude upper gastrointestinal bleeding, esophagogastroduodenoscopy was performed during which no clinically relevant findings were reported. Colonoscopy was attempted with a gastroscope and without previous purge. Fresh blood with numerous coagula was found in the rectum (▶Fig. 1 a), while the mucosa between the sigmoid andmid-transverse colon was covered with old blood (▶Fig. 1b). The cecum was not reached. The rectum was carefully re-examined and, after cleansing, a 10-mm 0-Isp polyp was discovered at 12 cm from the anal verge (▶Fig. 2 a). Active oozing of venous-type bleeding was observed from the tip of the polyp. Resection using a hot snare without submucosal injection was performed (▶Fig. 2b) and the postpolypectomy defect was closed with two hemoclips (▶Fig. 2 c, ▶Video 1). After an uneventful 24 hours of observation, the patient was discharged home. Histology analysis revealed an 8×6×5mm lobular capillary hemangioma with erosion on the mucosal surface. Also known as pyogenic granuloma, lobular capillary hemangiomas are most common in nasal mucosa and skin [1], and are very rare in the small and large intestine [2]. The typical presentation is gastrointestinal bleeding with or without anemia or abdominal pain. Massive bleeding is rare, although historical literature describes cases of death from exsanguination [3]. We have described a case of massive bleeding from a small polypoid rectal lobular capillary hemangioma in a previously healthy man, which was successfully removed by snare polypectomy with electrocautery.