3140 An Unfortunate Triad: GI Bleed Due to Refractory DLBCL Complicated by Occlusive Thrombus of the Inferior Vena Cava

Abstract

INTRODUCTION: Ileal ulcers are circumscribed, inflammatory and necrotic erosive lesions on the mucosal surface of the ileum and can have specific etiologies such as Crohn's disease, NSAID-intake, intestinal tuberculosis and eosinophilic enteritis. Here, we report a symptomatic terminal ileal ulcer caused by a diffuse large B-cell lymphoma (DLBCL). CASE DESCRIPTION/METHODS: A 71 year-old male with a history of gastrointestinal bleeds (GIB) due to ulcers presented with weight loss and small bowel obstruction due to a terminal ileum mass and was diagnosed with an EBV-negative DLBCL after a right hemicolectomy. In the setting of refractory disease (RCHOP, Ibrutinib and Lenalidomide on trial, salvage with DHAX) he presented again with an active GIB with hematemesis and dark stools, an EGD was normal but a colonoscopy showed a lymphoma of the terminal ileum (TI). Clinical examination showed no abnormalities. Initial work up showed mild anemia and elevated creatinine (1.68). A CT abdomen and pelvis showed a progressive disease with new circumferential thickening of the small bowel in the right abdomen. A PET showed a progressive lymphadenopathy throughout the abdomen and pelvis. The GIB was managed with IV pantoprazole and sucralfate. A biopsy of the terminal ileum mass showed a recurrent DLBCL. The patient was considered for a regeneron trial but developed nearly occlusive deep vein thrombosis (DVT) that extended into his inferior vena cava (IVC) and led to a DVT in his left subclavian vein, so that he no longer was a candidate for trial. Given the active GIB, he was planned for the placement of an IVC filter, however, the occlusive thrombus in the IVC prevented the procedure. The goals of best supportive care were discussed with the patient. DISCUSSION: The gastrointestinal (GI) tract is the most common extranodal site involved by lymphomas. While GI tract involvement is usually secondary during progression of the disease, primary GI tract lymphoma is relatively rare. Diffuse large B-cell lymphomas are the most common lymphomas affecting the GI tract. GI lymphomas present with unspecific clinical features and are therefore difficult to distinguish from other conditions. The diagnosis is made by pathology. In this case, a biopsy was obtained from the TI mass confirming the diagnosis of refractory DLBCL with GI involvement. This patient developed an unfortunate combination of multiple complications interacting with the respective treatments.