Rectal cavernous hemangioma: is endoscopic submucosal dissection the new standard of care?

Cavernous hemangioma is a benign vascular tumor whose incidence is very low in the gastrointestinal (GI) tract. Usually, it arises from the submucosal vascular plexus. Rectosigmoid is the most frequent location. Anemia, pain, and rectal bleeding are the main symptoms. Endoscopic diagnosis is far from easy: a bluish polypoid lesion, sometimes pedunculated, with superficial vascular congestion is typical. On endoscopic ultrasound (EUS) it appears heterogeneous with hypoechoic and hyperechoic areas, the latter attributable to calcifications. Biopsies should be avoided, as they can cause massive hemorrhage. Sclerotherapy, embolization, and surgery have been the most considered treatment over the years 1. Endoscopic mucosal resection and endoscopic full-thickness resection have been described, but the best technique should be endoscopic submucosal dissection (ESD) 2 3.