A 54-year-old man was transferred to our hospital because of incidental detection of a suspected submucosal tumor in the sigmoid colon. The patient did not report any weight loss, chronic diarrhea or constipation, hematochezia, melena, or abdominal pain. He had a medical history of bronchiectasis and had undergone pulmonary lobectomy because of recurrent infection 11 years earlier. The results of physical examination and laboratory tests were unremarkable. Colonoscopy confirmed a 0.5 × 0.3 cm lesion in the sigmoid colon (A). EUS showed that it was derived from the submucosa and suggested the possibility of a submucosal tumor (B). A Doppler examination was not performed because we usually use miniprobe EUS for small lesions like this. The patient agreed to undergo endoscopic submucosal resection to confirm the diagnosis and to remove the lesion. A pulsating submucosal artery was observed (C, arrow), which spurted blood after a gentle touch (D). Hemostatic forceps were used to stop the bleeding (E), and the lesion was closed with 3 endoscopic clips (F). The patient was discharged 3 days later.
An abnormal submucosal artery mimicking the appearance of a submucosal tumor is rarely seen during colonoscopy. Our case will help a better understanding of the atypical appearance of vascular abnormalities. Early endoscopic intervention may help prevent a possibly lethal hemorrhage.
Disclosure
All authors disclosed no financial relationships.
Commentary The fundaments of endoscopy will always be important in clinical practice. This case illustrates a patient with a relatively small submucosal lesion of the colon who underwent EUS without Doppler evaluation. The lesion, initially thought to be a submucosal tumor, was, in fact, a vascular lesion. As would be expected, endoscopic submucosal resection of the lesion resulted in significant bleeding, which was controlled by endoscopic clip placement. The EUS in this case was performed with a miniprobe; this device has no Doppler capability. Doppler US would have revealed the true nature of the lesion before attempted resection.
It is fair to wonder why a standard echoendoscope was not used, given the sigmoid location, because many sigmoid lesions are reachable with the full instrument, and miniprobes are usually reserved for lesions in the proximal colon. It is also worth wondering why such a small submucosal lesion was selected for resection in the first place, given the patient’s lack of symptoms. Although this sequence of events could happen to any endosonographer, I suspect the authors will be more reliant on Doppler US in the future.
Douglas G. Adler, MD, FASGE, GIE Senior Associate Editor, University of Utah School of Medicine, Salt Lake City, Utah
Mohamed O. Othman, MD, Associate Editor for Focal Points
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Publication history
Published online: January 07, 2020
Mohamed O. Othman, MD, Associate Editor for Focal PointsIdentification
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© 2020 by the American Society for Gastrointestinal Endoscopy
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