Obscure Cause of Upper Gastrointestinal Hemorrhage

A 31year-old man presented to an outside institution’s emergency department with headache, vomiting and no signs of bleeding. With decreased hemoglobin (hgb) of 4.6g/dl and normal head computerized tomography (CT), he was discharged on iron supplement. He presented to our emergency department 3 weeks later with weakness, tachycardia, hypotension, hgb of 5g/dl and a positive fecal occult blood test. With a normal colonoscopy and CT enterography, the patient was discharged to receive biweekly transfusions, and later underwent an outpatient small bowel capsule. Two months later the patient presented with weakness with no overt signs of bleeding and hgb was 4.2g/dl. Push enteroscopy identified a nearly circumferential mass in the proximal jejunum with stigmata of recent hemorrhage. Subsequently six months from the initial presentation, the patient underwent laparoscopic small bowel resection of a 7.3cm friable mass. The histopathology confirmed the endoscopic biopsy findings of a benign lymph vascular proliferation, favoring lymphangioma and an adjacent mesenteric lymph node with marked sinusoidal lymphangiectasia. One week post-surgery, the patient reported feeling well with an increased hgb of 7.1g/dl.