Recurrent Lymphoma in the Terminal Ileum

Document Type

Article

Abstract

Introduction: Malignancy in the small bowel is rare, representing less than 5% of all gastrointestinal cancers. Lymphoma of the small bowel is 1 of the most common types of primary gastrointestinal lymphoma, with Diffuse large B-cell lymphoma (DLBCL) most often presenting in the terminal ileum due its abundance of lymphoid tissue. Its presentation can vary, often presenting with similar symptoms to other conditions such as Crohn’s disease, small bowel obstruction, or appendicitis. Diagnosis is established by a combination of imaging and biopsy samples. The management of small bowel lymphoma involves surgical resection followed by adjuvant chemotherapy and, in some cases, radiation therapy.

Case Description/Methods: Here we present a case of a 25-year-old man with a history of terminal ileal DLBCL diagnosed 10 years prior, which was treated with partial small bowel resection and adjuvant chemotherapy. Exploratory laparotomy a year later was performed for recurrent distal small bowel obstruction, where he underwent additional small bowel resection and biopsy of 2 nearby lymph nodes. Pathology showed extensive, transmural granulomatous inflammation without recurrence of lymphoma, and flow cytometry was negative for a clonal B cell population. Surveillance colonoscopy several years later showed a grossly normal terminal ileum, with no evidence of residual lymphoma. However, he soon developed a perianal fistula with biopsies showing active inflammation despite his biomarkers not being suggestive of Crohn’s disease. He had been doing well until he developed epigastric pain that persisted for a few months without any dysphagia, dyspepsia, hematemesis, melena, right upper quadrant pain, Nonsteroidal anti-inflammatory drug use, excessive alcohol use, or B symptoms. Computed tomography scan showed mural thickening of the terminal ileum and colonoscopy revealed abnormal mucosa in the terminal ileum. Biopsies ultimately revealed a prominent infiltrate of large, atypical lymphocytes. Immunohistochemical staining identified these cells as CD20 positive B cells, suggestive of recurrent/residual disease. He was referred to surgical oncology and medical oncology for additional management.

Discussion: The presentation of DLBCL in the terminal ileum highlights the importance of considering a broad differential diagnosis when encountering nonspecific gastrointestinal symptoms. The combination of imaging, endoscopy, and biopsy samples is essential in making an accurate diagnosis.

First Page

S3073

Last Page

S3074

DOI

10.14309/01.ajg.0001048860.14521.49

Publication Date

10-1-2024

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