Image of the month: Ulcerated ileal mass in an 11‐year‐old male

An 11-year-old male presented with painless melena, tachycardia, and hemoglobin 4.3 g/dL. Platelet count, international normalized ratio, chemistry, and abdominal ultrasound with doppler were normal. He received two units of packed red blood cells and underwent an upper endoscopy and colonoscopy without bleeding source found. Video capsule endoscopy (VCE) and Meckel's scan were negative. Given ongoing melena requiring multiple transfusions, the patient underwent an antegrade double balloon endoscopy (DBE), where a mid-ileal 15 mm ulcerated submucosal lesion was found and tattooed (Figure 1). Pediatric Surgery performed a diagnostic laparoscopy, where the tattooed bowel was identified and small palpable mass noted. The lesion was resected, and small bowel primary anastomosis was performed. The patient recovered and was discharged home without further bleeding. Pathology showed an intravascular benign proliferation that was contiguous with the luminal surface. The lesion was composed of spindle cells with morphologic and immunophenotypic features of intravascular papillary endothelial hyperplasia, also known as “Masson's tumor” (Figures 2-4). This lesion is a reactive process secondary to thrombus formation and subsequent venous stasis. It is rare in the intestinal tract with only a handful of reported cases in the literature.1-3 The differential for melena in a child is broad and includes etiologies like peptic ulcer, varices, infections like Helicobacter pylori, Meckel's diverticulum, intussusception, anastomotic ulcer, and vascular malformations. Despite the rarity of small bowel tumors in children, they should remain on the differential for gastrointestinal bleeding when a source is not readily identified. Identification in this case may have been limited on standard evaluation due to bowel preparation quality and lack of active bleeding. Benign vascular tumors are reported primarily in adults with few reported cases of gastrointestinal vascular tumors in pediatric literature, most of which are extraintestinal.2-6 VCE and DBE, as well as immunostains for genetic and oncologic causes aid significantly in the diagnosis.7 Management involves resection, with endoscopic resection preferred for small lesions and surgical resection preferred for larger lesions and those at risk for malignancy progression such as leiomyosarcoma.8 Risk of recurrence is low in cases with clear surgical margins.2 The authors declare no conflicts of interest. Parental consent for publication was obtained for the patient described in this case.