Chronic abdominal pain with a difficult diagnosis

Abstract

A 74-year-old man attended our gastroenterology outpatient clinic with hipogastric aching pain for the past 5 years associated with recent worsening of chronic constipation. Physical examination as well as abdomino-pelvic ultrasound and colonoscopy was unremarkable. Anti-antispasmodics and dietary measures did not improve the clinical condition. For this reason, we performed an abdomino-pelvic computed tomography (CT) scan which showed thickening of the terminal ileum. The patient repeated colonoscopy with ileoscopy and regular hogback in the terminal ileum was observed that could not be overcome, lined by normal mucosa. It was biopsed, but histologic examination was normal. The entero-resonance was suggestive of nonspecific mesenteritis, but did not reveal changes in small bowel. Serologies to Crohn’s disease and celiac disease were negative. A video capsule enteroscopy was performed which revealed diffuse pattern of linfagiectasia and segmental pseudopolypoid whitish areas in jejunum and ileum (Fig. 1). Through push enteroscopy (Fig. 2) with a pediatric colonoscope, biopsies of proximal jejunum were taken. Microscopic examination demonstrated neoplastic proliferation of lymphoid tissue with follicular pattern (Fig. 3). The tumor cells were positive for CD20, CD10, BCL2, BCL6 and negative for CD3, CD5, CD23, and 5 blasts per high power field were observed. Based on these findings, a diagnosis of follicular lymphoma grade 1 was established.