2642 Diffuse Large B-Cell Lymphoma Presenting as Partial Small Bowel Obstruction and a Fistula

Abstract

INTRODUCTION: Non-Hodgkin lymphoma (NHL) is one of the most common cancers in the United States, accounting for 4% of all cancers. Diffuse Large B-Cell Lymphoma (DLBCL) the most common type of NHL. Gastrointestinal (GI) tract is a significant site of extranodal NHL and accounts for 30%–40% of all extranodal NHL. Out of this, 44 % are due to DLBCL. Ileocecal DLBCL accounts for 9.7% to 15% of total GI DLBCL. They lack specific symptoms and diagnosed when complications occur. We report a case of elderly male hospitalized for partial small bowel obstruction and a possible fistula due to DLBCL involving the ileocecal valve extending to the ileum. CASE DESCRIPTION/METHODS: A 75-year-old male presented with complaints of abdominal pain, nausea, and nonbilious vomiting for a day. He denied any fever, chills, sick contact, night sweat, or weight loss. On physical exam, he had moderate lower abdomen tenderness without palpable masses. CT scan of the abdomen and pelvis showed partial small bowel obstruction with a transition point at an ileocecal junction with amorphous soft tissue at the level of the terminal ileum and possible stricture or neoplastic involvement (Figure 1). Three days later, he had a colonoscopy which showed a large mass behind the ileocecal valve with a fistula (Figures 2 and 3). We were unable to intubate the ileocecal valve. Multiple biopsied taken from the mass that confirmed the diagnosis of DLBCL. PET scan showed cecal mass without any distal involvement. As recommended by surgery and oncology consultations, he had right hemicolectomy. DISCUSSION: Ileocecal region is a rare place for DLBCL occurrence. Majority of the cases are diagnosed incidentally or when complication like obstruction, perforation, or bleeding occurs like our patient who had bowel obstruction on presentation. We also found a fistula in cecum during colonoscopy. Clinically we suspect fistula as the patient was able to tolerate diet and complete bowel preparation easily in spite of having complete closure of ileocecal valve on colonoscopy. Due to the lack of oral contrast, it was not identified on the initial CT scan. Endoscopic features of DLBCL are nondiagnostic. The only way to confirm a diagnosis is, immunohistopathology staining specific for DLBCL. Majority of ileocecal DLBCL are at stage I or II diseases at the time of diagnosis. Surgical resection followed by chemotherapy had shown prolongation of survival. In conclusion, ileocecal DLBCL should be considered as a differential diagnosis for bowel obstruction or fistula.