A pseudotumoral angiodysplasia

A 76-year-old woman presented with recurrent right lower quadrant pain associated with decreased appetite and weight loss. An abdominal computed tomography (CT) scan without contrast injection (iodine allergy) showed a thickening of the cecal wall with infracentimetric regional lymph nodes ([Fig. 1]).

Fig. 1 A computed tomography of the abdomen showing a thickening of the cecal wall.

Colonoscopy depicted a 4 × 2-cm indurated and ulcerated lesion with necrotic features facing the ileocecal valve ([Fig. 2]).

Fig. 2 Endoscopic view of the ulceronecrotic lesion facing the ileocecal valve.

Laboratory tests were normal except for a slightly elevated carcinoembryonic antigen at 9.6 ng/mL (normal value: < 4.5 ng/mL). The pathologic analyses from the biopsies showed necrotic tissue without signs of malignancy. Despite negative histology, given the clinical presentation, and endoscopic and imaging studies, the patient underwent a right hemicolectomy. Macroscopic study of the resected specimen found an ulcerative lesion of size 3.5 cm near the ileocecal valve. Microscopic examination revealed richly vascularized granulation tissue ([Fig. 3]) containing arterialized veins (arrows).

Fig. 3 Microscopic examination of the surgical specimen revealed richly vascularized tissue containing arterialized veins (arrows).

The mucosa and the submucosa exhibited increased numbers of dilated and deformed vessels ([Fig. 4]).

Fig. 4 Microscopic examination of the surgical specimen showing increased numbers of dilated and deformed vessels within the mucosa and the submucosa.

In the absence of nonsteroidal anti-inflammatory drug use and ischemic findings, all these pathologic features are consistent with the diagnosis of ulcerated angiodysplasia of the cecum.

Typical lesions of angiodysplasia are red and small (diameter 4 – 8 mm) [1]. Colonoscopy is the gold standard for detecting symptomatic or asymptomatic lesions. It has a sensitivity of 68 % with a predictive positive value of 90 % [2]. Two cases of angiodysplasia have been described with a radiologic aspect typical of adenocarcinoma [3] [4]. In both cases, it presented as a sessile mass, with adjacent ulceration in one case, and surgery was performed. The originality of this case comes first from the clinical presentation – a 76-year-old woman with no presenting blood loss but with abdominal pain, lack of appetite and weight loss – features that are very unusual in the setting of angiodysplasia, and second from its atypical endoscopic presentation mimicking adenocarcinoma.

Endoscopy_UCTN_Code_CCL_1AD_2AF

References

• 1 Sharma R, Gorbien M J. Angiodysplasia and lower gastrointestinal tract bleeding in elderly patients.  Arch Intern Med. 1995;  155 807-812
• 2 Richter J M, Hedberg S E, Athanasoulis C A. et al . Angiodysplasia. Clinical presentation and colonoscopic diagnosis.  Dig Dis Sci. 1984;  29 481-485
• 3 Lu C, Fukuya T, Landas S. et al . Angiodysplasia of the colon mimicking adenocarcinoma.  AJR Am J Roentgenol. 1993;  160 898
• 4 Chiu M L, Liu G C, Liu C S, Chen C Y. Angiodysplasia mimicking colon cancer: colonoscopy, double contrast barium enema, and CT findings.  AJR Am J Roentgenol. 2007;  188 W456-W458