Small bowel hemangioma diagnosed with laparoscopy : Report of two pediatric cases

Hemangiomas of the small bowel are rare tumors that often present with gastrointestinal bleeding. Diagnosis can be difficult and exploratory laparotomy has often proved to be the only method with which to determine the presence and location of these tumors. We report two cases of small bowel hemangioma in children aged 10 and 7 years, in which the diagnosis was made by laparoscopy. Laparoscopy identifies the affected segment of bowel and allows delivery to a minimally extended umbilical port site. The avoidance of an open laparotomy helps to reduce post-operative analgesic requirement and achieves an early return of bowel function.


INTRODUCTION
Physical examination was unremarkable.Blood count revealed hemoglobin of 6.8 g/dL, mean cell volume Hemangiomas of the gastrointestinal tract are rare (MCV) of 72.Double contrast barium follows through and account for only 0.05% of all intestinal and Technetium 99 meter pertechnetate (Meckel's) neoplasms. [1]They are commonly found within the scan were normal.In addition, anti-endomysial and small bowel and comprise 7-10% of all benign autoimmune antibody screens were normal.
small bowel Diagnosis of small bowel tumors. [1]The commonest location within the small bowel is the mid-jejunum. [1]They have a tendency toward multiplicity with solitary tumors being extremely rare. [1,2]Hemangiomas have an association with systemic angiomatoses such as blue rubber bleb naevus syndrome, Maffucci's syndrome, and Klippel-Trenaunay-Weber syndrome.Grossly, an intestinal hemangioma is usually soft and polypoid; it is red, blue or wine-colored, and varies in size from a few millimeters to a large polypoid mass projecting into the lumen or infiltrating the bowel wall. [1]wever, fecal occult blood tests were positive on a number of occasions.Upper and lower gastrointestinal endoscopies were arranged, however, before these investigations could be performed, the patient presented acutely with collapse and melaena.Following fluid resuscitation, she underwent urgent oesophago-gastro-duodenoscopy (OGD) and colon oscopy, both of which revealed no abnormality.Lapar oscopy was undertaken at the same time and revealed a 2 cm vascular malformation of the jejunum [Fig ures 1 and 2], which was resected with primary jeje- ) .
Jones, et al.: Small bowel hemangioma diagnosed with laparoscopy to allow resection of the affected bowel segment and primary end-to-end anastomosis.She made an une ventful recovery and was found to have normal he moglobin and hematinics at follow up.Histology confirmed a cavernous hemangioma extending through the full thickness of the bowel wall.

DISCUSSION
Hemangiomas of the small bowel are rare tumors that often present with gastrointestinal bleeding.They are commonly found in the small bowel and hence often make diagnosis difficult.Initial Other investigations such as red blood cell scan and angiography have a rather low yield when the vascular malformation is not actively bleeding and one may have to resort to exploratory laparotomy to determine the presence and location these tumors. [1,3]paroscopy as employed in our two cases allows a diagnosis to be made without performing a umbilical port site.Resection and anastomosis is then She made an uneventful recovery and follow up at 6 performed in the usual manner.A port site is months revealed a normal blood count and hematinpositioned at the umbilicus for the laparoscope, with ics.Histology of the resected bowel confirmed a jetwo lower abdominal ports for instruments.The small junal vascular malformation.
bowel is examined from the ileocecal junction prox upper and lower The second patient was a 7-year-old girl who initially presented with a three weeks history of lethargy, anorexia, and abdominal pain.Physical examination was normal.On admission, her hemoglobin was 4 g/ dL with an MCV of 62 and required blood transfusion.
Fecal occult blood tests were negative.A Meckel's scan, abdominal ultrasound scan, OGD and colonos copy were normal.She underwent laparoscopy, which revealed a 2 cm hemangioma in the distal jejunum.
A mini laparotomy was performed via the umbilicus imally.Laparoscopy can be performed in conjunction with upper and lower gastrointestinal endoscopy under the same anesthetic, as in our first case.Prior insufflation of the gastrointestinal tract during en doscopy did not create any difficulties for the lapar oscopy or identification of the pathology in this case.The avoidance of an open laparotomy helps to re duce post-operative analgesic requirement and achieves an early return of bowel function.Furthermore, there is the added cosmetic benefit of the small umbilical scar in girls.) .
Jones, et al.: Small bowel hemangioma diagnosed with laparoscopy Laparoscopy in these two cases also allowed a thor ough examination of the whole length of small bow el using the 'walking' maneuver.The good light source and magnification enabled easy viewing of any mesenteric or seromuscular abnormalities.We did not proceed to intra-operative small bowel endoscopy as we felt that additional large hemangi omas were unlikely.We were also confident that the resected specimen had had a recent bleed because of the eroded appearance of the mucosal surface of the hemangioma when examined intra-operatively.We believe laparoscopy compliments other modalities in l i c a t i o n s ( w w w .m e d k n o w .c o m l i c a t i o n s ( w w w .m e d k n o w .c o m

Figure 1 :
Figure 1: Laparoscopic view of the jejunal hemangioma

Figure 2 :
Figure 2: Opened specimen showing ulcerated haemangioma on the l i c a t i o n s ( w w w .m e d k n o w .c o m