Chronic GI bleeding in a middle-aged woman

CLINICAL PRESENTATION: A middle-aged woman without any underlying systemic disease was referred to our hospital due to a 1-month history of recurrent black diarrhoea and anaemia. At presentation, her vital signs were stable and the physical examination was unremarkable except for pale conjunctiva. Laboratory tests showed iron-deficiency anaemia with a haemoglobin concentration of 7.3 g/dL (reference range, 11.1–15.1 g/dL). As she had no severe symptoms of anaemia, we administered oral iron preparations without blood transfusion and her anaemia was gradually corrected. Oesophagogastroduodenoscopy, colonoscopy and contrast-enhanced abdominal CT revealed no cause of bleeding, so obscure GI bleeding was suspected. Capsule enteroscopy revealed black fluid in the proximal small intestine, and subsequent peroral double-balloon enteroscopy detected a 1 cm diameter hemispheric elevated lesion at the upper jejunum (figure 1A, B). The lesion was non-pulsatile and hard in consistency, appearing as a submucosal tumour (SMT). An ulcer was located at the top of the lesion, suggesting the source of bleeding, although no blood clot was present around the site. QUESTIONS: What is your diagnosis? Do you try to obtain biopsy specimens from this lesion?