A rare cause of small-bowel bleeding: haemorrhagic small-bowel lymphangioma diagnosed by antegrade double-balloon enteroscopy.

Small-bowel lymphangiomata (SBLs) are benign and relatively uncommon tumors of the lymphatic system [1]. Although SBLs are usually clinically silent, they may rarely present with significant small-bowel bleeding, protein-losing enteropathy, and intussusception [2, 3]. A 54-year-old-man with a past medical history of stable chronic lymphocytic leukemia presented with transfusion-dependent obscure-overt gastrointestinal (GI) bleeding. Upper and lower GI endoscopies and small-bowel cross-sectional imagining were unremarkable. A smallbowel video capsule endoscopy (VCE) showed a white-speckled congested lesion, with active oozing (▶Fig. 1). The lesion was estimated to be about 2 cm in diameter and was deemed to be located within the jejunum. Antegrade double-balloon enteroscopy (DBE) was subsequently performed. The enteroscope was advanced to an estimated insertion depth of 240 cm post-pylorus, where the lesion seen at VCE was identified (▶Fig. 2, ▶Video1). This had a white–yellow appearance with overlying severely congested villi giving a “strawberry-like” mucosal pattern. The lesion was not deemed to be endoscopically resectable; multiple biopsies were taken and a reference tattoo was placed proximal to it. Histopathological exam confirmed a lymphangiomatous etiology without any evidence of dysplasia or malignancy (▶Fig. 3). Minimally invasive tattooguided laparoscopic resection has been planned. This case highlights the key, complementary role of small-bowel VCE and DBE for the diagnosis and minimally invasive management of clinically significant SBLs.