Small bowel cavernous hemangioma is an uncommon benign vascular tumor, representing <0.05% of all gastrointestinal neoplasms (1). Hemangiomas are histologically classified as capillary, cavernous, or mixed types, with cavernous hemangioma being the most common subtype affecting the small intestine, especially the jejunum (2). These lesions may present with abdominal pain, obstruction, or gastrointestinal bleeding. When gastrointestinal bleeding persists despite non-diagnostic esophagogastroduodenoscopy (EGD) and colonoscopy, it is classified as obscure overt gastrointestinal bleeding (OOGIB) (3). Because 5–10% of gastrointestinal bleeding originates from the small intestine (4), small bowel lesions must be considered in patients with recurrent or persistent bleeding when a routine evaluation fails to identify the bleeding source.

We report a 40-year-old woman presenting with recurrent melena and post-prandial bloating for one year requiring multiple blood transfusions due to persistent severe anemia. On examination, she had severe pallor, and markedly reduced hemoglobin to 5.4 g/dL. Preliminary investigations, EGD, colonoscopy, and CT angiography were essentially normal. Further CT enterography detected a hyperdense, arterial enhancing submucosal lesion in the small bowel. Capsule endoscopy showed aphthous ulcers and erosions in the proximal ileum, and double balloon enteroscopy (DBE) identified a subepithelial lesion measuring 1 × 1 cm with central umbilication. Endoscopic biopsy was deferred due to high risk of bleeding associated with vascular lesions and surgical excision was planned.

Exploratory laparotomy revealed a subepithelial mass (0.8 × 0.6 cm) in the distal jejunum. Segmental jejunal resection with primary anastomosis was performed. Histopathology demonstrated dilated vascular spaces lined by flattened endothelial cells, consistent with cavernous hemangioma. The patient remained symptom free postoperatively and subsequent follow up for a year.

Cavernous hemangiomas of the small bowel are rare and may arise from any wall layer, from mucosa to serosa. A limited number of cases have been reported in India over the past decade. Most patients present with anemia or melena, sometimes complicated by obstructive features (5). Capsule endoscopy and DBE are key diagnostic tools for identifying these lesions when conventional endoscopy is inconclusive. Surgical resection offers definitive treatment, especially in symptomatic lesions.

This case highlights the need to consider cavernous hemangioma in patients with unexplained anemia and OOGIB and emphasizes the diagnostic importance of advanced enteroscopic techniques.