An unusual cause of bleeding from the duodenum: pyogenic granuloma.

A 65-year-old man was referred to our hospital because of melena and chest pain due to anemia. Medical history disclosed type 1 diabetes mellitus, an acute coronary syndrome, pacemaker implantation because of a sick sinus syndrome and an occlusion of the superior temporal artery. The patient used a coumarin derivative. During admission, the patient had large volume melena and became hemodynamically unstable, requiring erythrocyte transfusion. After stabilization and correction of coagulation, an upper gastrointestinal endoscopy was performed, which revealed an oozing 10-mm diameter strawberry-like polypoid lesion in the second part of the duodenum near the major papilla (Figs. 1, 2). After reaching haemostasis through epinephrin injection, a biopsy was taken. The histological examination (Fig. 3) showed proliferation of capillaries (A) with a mononuclear cell infiltrate (B) in the lamina propria, consistent with a pyogenic granuloma (C: crypt, remnant of duodenal mucosa) (H&E x200). A pyogenic granuloma, i.e. a lobular capillary hemangioma is a benign vascular tumor, usually arising on the skin and in the oral cavity. The exact etiology is unknown, but possible triggers include mechanical irritation and pregnancy [1]. In the gastrointestinal tract, a pyogenic granuloma is a rare condition. The commonest sites are the small intestine, esophagus and colon, but they can occur throughout the entire gastrointestinal tract. In the literature, we found two other cases of a pyogenic IMAGE OF THE ISSUE