Massive Hemorrhage in Pregnancy Caused by a Diffuse Cavernous Hemangioma of the Rectum -- EUS as Imaging Modality of Choice

Klaus Gottlieb, MD; Philip Coff, MD; Harold Preiksaitis, MD; Adam Juviler, MD; Peter Fern, MD


September 03, 2008

Introduction and Case Report


Diffuse cavernous hemangiomas of the rectum are rare tumors, with approximately 120 cases described worldwide. This is the first report we have identified in which diagnostic endorectal Doppler ultrasonography images are presented. The case is also unique because early delivery was required secondary to the life-threatening severity of the bleeding. Familiarity with this condition and the use of selected imaging modalities can avoid a delay in diagnosis and avoid inappropriate treatments.

Case Report

The patient is a 29-year-old gravida 3, para 2, who presented at 35 weeks for cesarean section. The patient had had no problems with rectal bleeding during prior pregnancies, but in the second and third trimester of the current pregnancy she had severe recurring hemorrhage. She was seen by 2 gastroenterologists and a colorectal surgeon who identified oozing varicosities in the distal rectum. It was not felt that banding or surgical ligation would be helpful, but that presumably the congestion and bleeding would improve or resolve following delivery. She required 2 hospitalizations and received multiple transfusions; however, toward the final weeks of her pregnancy the bleeding increased to the point where she was losing 1 to 2 units of red blood cells per day. Rectal bleeding improved significantly immediately after delivery. CT of the abdomen and pelvis was ordered to rule out liver disease and portal venous pathology. Diffuse thickening of the rectum and distal sigmoid wall as well as multiple punctate calcifications were seen. The radiologist thought that an inflammatory process was the most probable cause (Figure 1).

Figure 1.

This coronal reformatting of abdominopelvic CT shows rectal wall thickening and clustered punctate calcifications. An inflammatory process was thought to be the most probable cause.

Based on the CT appearance and the clinical presentation, a differential diagnosis of diffuse cavernous hemangioma of the rectum was considered by one of us, and the patient was referred for anorectal endoscopic ultrasonography (EUS) with the Doppler-equipped electronic radial echoendoscope (GF-UE 160, Olympus Co, Center Valley, PA). The following images show pulsatile arterial flow demonstrated by power-Doppler and a sponge-like mass with vascular channels surrounding the rectum (Figures 2 and 3).

Figure 2.

Pulsatile flow into the rectal cavernous hemangioma with a large feeding vessel clearly visible close to the 6 o'clock position. The images were obtained with the GF-UE160 Doppler echoendoscope.

Figure 3.

This grayscale rectal ultrasonogram clearly shows the sponge-like nature of the cavernous hemangioma as it protrudes into the rectal lumen.

The classic findings of a diffuse rectal hemangioma were also seen on MRI (Figure 4) performed subsequently. The hemangioma extended through the internal sphincter to the level of the external sphincter. The patient is currently unsure whether she should pursue surgery because the bleeding has stopped.

Figure 4.

These are T2- (left) and T1-weighted (right) MRI images.

Characteristically, hemangiomas demonstrate bright signal intensity on T2-weighted images and intermediate signal intensity on T1-weighted images. Calcifications and blood vessels are signal-voided on both T1- and T2-weighted images, but thrombosed vessels have high signal intensity.


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