A 74-year-old male with previous history of diverticulosis presented to the emergency department for the third time in a month with complaints of hematochezia. Patient reported a 10kg weight loss in the past month. Blood test results revealed hemoglobin 11.7g/dL. Colonoscopy showed an elevated 30mm lesion with central mucosal disruption and active bleeding, located at the splenic flexure of the colon (Fig 1A-B). Endoscopic hemostasis was achieved with diluted adrenaline, through-the-scope clips, and hemostatic powder (Fig 1C-D).  Biopsies were performed but inconclusive. CT angiography revealed a 7.5 x 5.5 cm lobulated, exophytic lesion with peripheral enhancement and central hypodense areas, extending from the transverse colon and in direct contact with the pancreatic tail (Fig2). This also showed perilesional adenopathies and multiple liver metastases.

An endoscopic ultrasound (EUS) was performed for further characterization and tissue sampling was done using a fine 22 G needle biopsy (FNB). The referred lesion appeared hypoechoic and heterogeneous with internal anechoic areas (Fig3).