A 75-year-old woman, under study for signs and symptoms of microcytic hypochromic anemia of 3-year progression, was treated on several occasions with oral iron supplementation and blood transfusions. She presented with hemorrhoidal pathology and dark stools related to iron therapy. Her latest control laboratory work-up reported Hb 10g/dl, MCV 72 f/l, iron 47μg/dl, ferritin 250ng/ml, vitamin B12 378pg/ml, and folic acid 6ng/ml. Upper gastrointestinal endoscopy revealed mild erythematous gastritis, with a large sliding hiatal hernia, and colonoscopy showed internal hemorrhoids and a spastic colon. There were no signs of active bleeding in either study. Due to the suspicion of occult bleeding, scintigraphy with red blood cell labeling with 99mTc-stannous pyrophosphate (Fig. 1A and B) and abdominal SPECT/CT (Fig. 1C and D) were performed, identifying endoluminal radiotracer uptake at the distal end of the ascending colon consistent with low output bleeding. In addition, a rounded and well-delineated area of increased uptake in liver segment V that corresponded to a hemangioma was identified. The abdominal CT scan with iv contrast medium (Fig. 2) revealed the typical centripetally progressive enhancement pattern, supporting the diagnosis of hepatic hemangioma, with no signs of alterations in the intestinal segments. The patient was treated with 100mg of trivalent iron for 2 weeks. The upper gastrointestinal endoscopy, barium transit, and colonoscopy were repeated and showed no significant alterations. The patient is currently asymptomatic, with stable Hb values in the control laboratory tests.

Figure 1.

Scintigram with red blood cells labeled with 99mTc-stannous pyrophosphate, dynamic images during the course of one hour: physiologic distribution of the radiotracer, with no signs of bleeding foci. Morphologic nodular area of increased uptake in the right hypochondrium (green arrow) (A). Late images at 24h post-injection: area of increased uptake persists at the level of the right hypochondrium (green arrow). Newly appearing low intensity and diffuse uptake in the right iliac fossa (red arrow) (B). Abdominal SPECT/CT at 24h post-injection: endoluminal radiotracer uptake at the distal end of the ascending colon, increasing its activity over time, consistent with low output bleeding (C). Nodular image with increased uptake in liver segment V, indicative of a fixed vascular structure (hemangioma) (D).

(0.3MB).

Figure 2.

Axial view of the abdominal CT scan with iv contrast medium: focal lesion with peripheral nodular enhancement (approximately 5.1×4.6cm) located in liver segment V, consistent with an exophytic hemangioma.

(0.05MB).