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Purpose: Lower intestinal venous malformations are rare anomalies resulting from errors in vascular morphogenesis. These lesions may cause significant chronic and acute gastrointestinal hemorrhage. Venous malformations are unresponsive to angiogenesis inhibitors. Though these anomalies are generally incompletely resectable due to diffuse pelvic and mesenteric involvement, we sought to abate bleeding by excluding the lesion from the gastrointestinal lumen. Methods: Three patients with circumferential transmural venous malformations of the colorectum, pelvis and mesentery were identified. Imaging findings were similar among the patients, and included circumferential septated bright signal on T-2 weighted MRI, contrast enhancement, and multiple phleboliths, seen best on CT. The lesion extended from the anus to the splenic flexure in two patients and throughout the entire colorectum in the other. Each had daily hematochezia for many years and required transfusions (estimated over 100 units in one case) and chronic iron therapy. Though bleeding began in early childhood in each patient, no therapy was successful until ages 7,24, and 45. Colectomy, anorectal mucosectomy (through the pelvic venous malformation), and endorectal pull-through and anastomosis was performed (coloanal in two and ileoanal in one). Results: Bleeding has been essentially eradicated in all three patients with 5 to 52 month follow-up. One patient received a three unit transfusion intraoperatively and the other two received none. The most recently operated patient, who has residual venous malformation in the remaining 1 cm of anal mucosa, has some mild difficulty with fecal control if her diet results in loose stool. Conclusion: Colectomy with mucosectomy and endorectal pull-through should be considered for diffuse venous malformations of the colorectum prior to the development of large transfusion requirements., SJ Fishman MD, FAAP; RC Shamberger MD, FAAP; V Fox MD, PE Burrows MD; Children's Hospital, Boston, MA [...]