Vol.:(0123456789) 1 3 Clinical Journal of Gastroenterology https://doi.org/10.1007/s12328-018-0891-z CASE REPORT Pyogenic granuloma of the ampulla of Vater: unexpected cause of gastrointestinal bleeding Helena Moreira Silva 1  · Gisela Silva 1  · Emília Costa 2  · Rosa Lima 1  · Fernando Pereira 3 Received: 17 June 2018 / Accepted: 2 August 2018 © Japanese Society of Gastroenterology 2018 Abstract We describe the case of a previously healthy 8-year-old girl presenting with a 1-year history of iron defciency anemia. There was no report of hematemesis, abdominal pain or melena. Laboratory work-up excluded iron malabsorption as the underlying cause. Therefore, endoscopic evaluation was performed to exclude gastrointestinal blood loss, which revealed the presence of a 7 mm reddish lesion located within the ampulla of Vater. Capsule endoscopy excluded alternative diagnoses and con- comitant lesions. Histopathological examination confrmed the diagnosis of pyogenic granuloma. The young age of the child and the benign nature of this lesion along with the absence of complications favored conservative management. Pyogenic granuloma is a benign vascular lesion that presents as a polypoid red mass. In the gastrointestinal tract, it is a rare condition and occurs more commonly in the elderly. The most common sites are the small intestine, esophagus, and colon, but they can occur throughout the entire gastrointestinal tract with a propensity to bleed that may cause iron defciency anemia. In pediatric age patients, there are few reports of gastrointestinal pyogenic granulomas, most of which occur in the colon and rectum. Its identifcation and location in the ampulla of Vater is an exceptional fnding. Keywords Ampulla of Vater · Iron defciency anemia · Gastrointestinal bleeding · Pyogenic granuloma Introduction Pyogenic granuloma (PG) (also known as lobular capillary hemangioma) is a benign vascular proliferation that occurs mostly on the skin and in the oral mucosa, which most com- monly afects children and young adults. However, PG in the gastrointestinal tract is very rare and often occurs in the elderly [1, 2]. Trauma, irritation, underlying arteriovenous malformations, and the overproduction of angiogenic growth factors have all been proposed to play a potential role in its development. They manifest as a solitary sessile or pedunculated polypoid lesion that is prone to bleeding and ulceration. Indeed, gastrointestinal PG is a rare cause of gastrointestinal bleeding but should be considered in the diferential diagnosis of chronic gastrointestinal bleeding and iron defciency anemia. We report on a child with iron defciency anemia whose diagnostic work-up indicated the diagnosis of PG located within the ampulla of Vater. Clinical case An 8-year-old girl was referred because of a 1-year his- tory of iron deficiency anemia associated with fatigue and pica. She denied hematemesis and abdominal pain, and there was no change in weight, bowel pattern, or stool color. Her medical history was unremarkable, and her physical examination was normal. The laboratory data (complete blood count, biochemistry, and urinaly- sis) evidenced hypochromic and microcytic anemia with a hemoglobin level of 9.3 g/dL, normal platelet count, and normal coagulation parameters and inflammatory mark- ers. An iron study revealed a serum iron level of 14 µg/dL (reference range 50–150 µg/dL) with a total iron binding capacity of 398 µg/dL (reference range 258–389 µg/dL), and ferritin of 3.0 ng/mL (reference range 2–178 ng/mL). * Helena Moreira Silva hel.m.silva@hotmail.com 1 Pediatric Gastroenterology Unit, Centro Materno Infantil do Norte, Oporto Hospital Center, Largo Maternidade Júlio Dinis, 4050-371 Porto, Portugal 2 Pediatric Hematology Unit, Centro Materno Infantil do Norte, Oporto Hospital Center, Porto, Portugal 3 Pediatric Gastroenterology Unit, Oporto Hospital Center, Porto, Portugal