P2005 - A Big Problem in the Small Intestine: A Rare Case of Small Bowel Lymphoma with Acute Presentation

John F. Galatowitsch, MD, Mark Zivney, MD, John P. Haydek, MD, Gregory Austin, MD, MPH
University of Colorado Anschutz Medical Campus, Aurora, CO

Introduction: The intestines are the most common extra-nodal site of lymphoma, but primary intestinal lymphomas are rare. These malignancies are difficult to diagnose as there are no specific symptoms, lab tests, or radiographic findings. Here we present a rare case of primary small bowel lymphoma initially concerning for infectious enteritis.

Case Description/Methods: A 64 year-old man presented with two weeks of progressive abdominal pain, abdominal distention and diarrhea. On presentation, he was tachycardic but otherwise stable. His abdomen was distended with tenderness to palpation in the epigastrium. Initial laboratory evaluation revealed WBC 15, Creatinine 1.4 (baseline 0.7), bicarbonate 17, albumin 3.6. Lactate 4.4 and CRP 148. EGD one month prior for esophagitis revealed a normal duodenum. CT abdomen and pelvis 12 days prior to admission showed small bowel thickening concerning for acute infectious enteritis with diagnosis anchoring noted in subsequent primary care and gastroenterology notes. On admission CT angiography of the abdomen and pelvis revealed a normal liver, patent abdominal vasculature, moderate ascites, and circumferential thickening of the duodenum and jejunum. Push enteroscopy revealed severe duodenitis characterized by circumferential ulceration and edema in the third and fourth portion of the duodenum. Duodenal biopsies resulted showing a high-grade, diffuse large B-cell lymphoma (Figure 1). The patient was started on etoposide, cyclophosphamide and prednisone leading to clinical improvement.

Discussion: Primary intestinal lymphomas make up only 1-4% of all GI malignancies. Approximately 90% of GI lymphomas are B-cell in origin with T-cell and Hodgkin’s lymphoma making up the rest. This patient’s presentation is typical for a small bowel lymphoma, but the acuity masqueraded as infection. It is a disease that most often presents in the sixth decade of life and affects men in a 3:1 ratio. Symptoms typically include abdominal pain, bloating, nausea, vomiting, weight loss, gastrointestinal bleeding, and bowel obstruction. This patient’s CT finding of intestinal thickening is not always present, but when present, infiltrating soft tissue with relative preservation of fat planes affecting multiple sites favors lymphoma over other GI malignancies. Diffuse large B-cell lymphomas are typically treated with chemotherapy. The gastroenterologist or general internist should not forget about intestinal lymphoma when evaluating older patients, men in particular, for non-specific GI symptoms.


Figure: Figure 1:
(A) The third portion and (B) fourth portion of the duodenum showing severe inflammation, edema, and ulceration with visible blood.
(C) Duodenal biopsy under high power with H&E stain revealing diffuse proliferation of atypical monomorphic lymphocytes within the lamina propria. The atypical lymphocytes are positive for CD20, PAX5, BCL2, CD10, BCL6, and MYC with nearly 100% proliferation index by Ki-67


Disclosures:
John Galatowitsch indicated no relevant financial relationships.
Mark Zivney indicated no relevant financial relationships.
John Haydek indicated no relevant financial relationships.
Gregory Austin indicated no relevant financial relationships.


John F. Galatowitsch, MD, Mark Zivney, MD, John P. Haydek, MD, Gregory Austin, MD, MPH. P2005 - A Big Problem in the Small Intestine: A Rare Case of Small Bowel Lymphoma with Acute Presentation, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.