From What’s Your Diagnosis? on page 6
This patient was diagnosed with diffuse cavernous hemangioma of the rectosigmoid colon. A flexible sigmoidoscopy was done and showed nodularity and blue-purple discoloration from the anal verge to a distance of 20 cm, suggestive of large submu- cosal vascular malformations. No active bleeding
was seen. Pelvic magnetic resonance imaging (MRI)/
magnetic resonance venogram was done and showed irregular circumferential wall thickening in the rectum and
sigmoid colon with phleboliths consistent with diffuse
cavernous hemangioma. Given the patient’s age, a sphincter-sparing operation was not pursued and an abdomino-perineal resection was performed to resect the involved
rectosigmoid colon. The patient expired 2 days after discharge from the hospital from apparent septic shock.
Diffuse cavernous hemangioma of the colon is a rare, nonmalignant, vascular malformation frequently misdiagnosed
as hemorrhoids or ulcerative colitis. The most common site
affected is the rectosigmoid colon.1 It is a congenital abnormality caused by embryonic sequestration of mesodermal
tissue. There have been roughly 350 cases reported in the
literature, with the vast majority in patients under the
age of 30.1 There is only one other case report of a patient
presenting in the ninth decade of life.
2 The most common
presenting symptom is recurrent painless rectal bleeding.
Characteristic findings on endoscopy are a confluence of ser-
piginous purple areas in the rectum with some nodularity
resulting from the dilated submucosal vascular structures.
Biopsy is best avoided owing to the risk of bleeding, and
in this case biopsies and treatment of the bleeding lesions
with a bipolar probe may have contributed to the patient’s
ongoing bleeding. On CT scan, diffuse concentric rectal
thickening with clusters of calcified phleboliths are pathog-
nomonic findings. In the absence of phleboliths on CT, MRI
can be diagnostic.
3 Moreover, MRI is much more accurate in
defining the extent of involvement of the anal sphincter and
adjacent structures, which can be crucial in planning sur-
gery.1 Definitive treatment requires surgical resection with a
sphincter-sparing operation when possible based on patient
factors including anal sphincter functional capacity and lack
of involvement of the anal canal by hemangioma. Angioem-
bolization has been used as well, but with limited and usual-
ly only temporary improvement in bleeding.
1. Wang, A. Y. Ahmad, N.A. Diffuse cavernous hemangioma of the colon and
rectum. Clin Gastroenterol Hepatol. 2007; 5 (xxv)
2. Veloso, N., Silva, J.D., Pinto-Marques, P. A rare cause of rectal bleeding.
3. Kandpal, H., Sharma, R., Srivastava, D.N. et al. Diffuse cavernous haemangioma of colon: Magnetic resonance imaging features. Report of two cases.
Australas Radiol. 2007;51:B147–51.