Transfusion-Dependent Anemia Secondary to Bowel Hemangiomas Managed With Sirolimus Therapy: A Case Report and Literature Review.

A real diagnostic challenge is posed by transfusion-dependent anemia in young patients with obscure gastrointestinal (GI) bleeding. Such a presentation can have many etiologies. Although rare, small intestinal hemangiomas are benign vascular tumors that frequently elude timely diagnosis owing to their intramural growth pattern and deep submucosal sequestration. Recent literature has increasingly shown the benefit of systemic therapies, such as sirolimus, for managing complex vascular anomalies. We report the case of a 17-year-old girl with a history of easy fatigability, melena, and exertional dyspnea, requiring regular red blood cell transfusions for the past six years. Initial laboratory investigations were suggestive of severe iron deficiency anemia, with a hemoglobin level of 6.3 g/dL and a ferritin level of 5.2 ng/mL. The stool occult blood test was positive. However, repeated upper and lower GI endoscopies and imaging were non-contributory. A repeat computed tomography angiography (CTA) of the abdomen was carried out, which showed intramural polypoidal lesions in the distal ileum and descending colon. Diagnostic laparoscopy was confirmatory of multiple small intestinal hemangiomas. In view of the multifocal nature of the lesions and the prohibitive risk of extensive bowel resection, a conservative strategy utilizing systemic mTOR (mechanistic target of rapamycin) inhibition was adopted. The patient achieved transfusion independence within two months, with a sustained normalization of hematological indices and a favorable side-effect profile. This case highlights the diagnostic complexity of small intestinal hemangiomas. It reinforces the role of imaging and laparoscopy, as well as the importance of considering rare causes, in transfusion-dependent anemia with chronic GI bleeding. In multifocal involvement of hemangiomas, sirolimus therapy may be an effective and safer alternative to surgical intervention. This case calls for more research and awareness of such rare vascular anomalies to accelerate diagnosis and management.