What is the management approach for an adult patient presenting with a submucosal hemangioma, potentially causing symptoms such as bleeding, pain, or obstruction?

Management of Submucosal Hemangioma in Adults

Symptomatic submucosal hemangiomas causing bleeding, pain, or obstruction should be considered for resection, while asymptomatic lesions require diagnostic confirmation via endoscopic ultrasound (EUS) followed by observation or tissue sampling. 1

Initial Diagnostic Approach

EUS is the modality of choice to evaluate any indeterminate subepithelial lesion (SEL) of the GI tract, including suspected hemangiomas. 1 This allows precise characterization of:

• Layer of origin (typically submucosa for hemangiomas)
• Size and depth of the lesion
• Vascular characteristics on Doppler imaging
• Relationship to surrounding structures

For tissue diagnosis, submucosal lesions can be sampled using tunnel biopsies, deep-well biopsies, EUS-guided fine-needle aspiration (FNA), EUS-guided fine-needle biopsy (FNB), or advanced endoscopic techniques such as unroofing or endoscopic submucosal resection. 1

Management Algorithm Based on Symptoms

Symptomatic Hemangiomas (Bleeding, Pain, Obstruction)

Endoscopic resection is the first-line treatment for symptomatic submucosal hemangiomas when the lesion is confined to the mucosal or submucosal layers. 2 The 2022 AGA guidelines explicitly state that subepithelial lesions that are ulcerated, bleeding, or causing symptoms should be considered for resection. 1

Specific endoscopic techniques include:

• Endoscopic submucosal resection (ESMR) for lesions confined to the submucosa 1
• Endoscopic submucosal dissection (ESD) for larger submucosal lesions not involving muscularis propria 1
• Submucosal tunnel endoscopic resection (STER) for difficult locations (cardia, proximal fundus) or when deeper involvement is suspected, though limited to lesions <3-4 cm 1

Laser photocoagulation (Nd:YAG laser) is highly effective for large hemangiomas, particularly in the hypopharynx and esophagus, with minimal hemorrhage risk and excellent outcomes. 3 This technique allows complete excision with rapid recovery and low recurrence rates.

Sclerotherapy with agents like aethoxysklerol (0.75-1%) is an alternative for superficial submucosal hemangiomas, particularly in the oral cavity, requiring 1-2 injections spaced 2 weeks apart. 4 For esophageal hemangiomas where endoscopic resection is not feasible, endoscopic injection sclerotherapy should be considered before surgical resection. 2

Asymptomatic Hemangiomas

Management depends on size, histopathology, malignant potential, and presence of symptoms. 1 For confirmed hemangiomas without symptoms:

• Observation with surveillance is appropriate for small lesions (<2 cm) 1
• No further evaluation or surveillance is needed if the lesion has characteristic endoscopic appearance and normal mucosal biopsies 1
• EUS surveillance should be considered for lesions arising from muscularis propria that are <2 cm 1

Critical Pitfalls to Avoid

Do not perform standard mucosal biopsies alone for diagnosis, as these rarely reach deep enough to obtain diagnostic tissue from submucosal lesions. 1 Instead, use forceps bite-on-bite, deep-well biopsies, or tunnel biopsies. 1

Do not attempt endoscopic resection without EUS characterization of the layer of origin, as risk of complications (bleeding, perforation) is directly related to tumor depth within the gastric wall. 1

Recognize that cavernous hemangiomas carry higher rupture risk due to larger blood-filled spaces and vessels, making them more likely to cause substantial bleeding. 5 These require more aggressive management even when minimally symptomatic.

Endoscopic resection should be limited to endoscopists skilled in advanced tissue resection techniques given the technical complexity and complication risks. 1

Surgical Considerations

Surgical resection (wedge resection or segmental resection) is indicated when:

• Endoscopic resection is not technically feasible due to size or location 2
• The lesion extends beyond the submucosa into muscularis propria or serosa 6
• Life-threatening bleeding occurs that cannot be controlled endoscopically 5
• The lesion is in a location where endoscopic perforation would cause significant morbidity (esophagus, duodenum) 1

For gastric hemangiomas, wedge resection has excellent long-term outcomes with minimal recurrence when complete excision is achieved. 6