Lymphoma Masquerading as Acute Abdomen

Abstract

Purpose: 45-year-old male presented to the hospital with sudden onset of right upper quadrant pain. The patient described the pain as sharp, intense, non-radiating which was preceded by one episode of non-bilious vomiting. Review of systems was positive for nausea, vomiting and chills. Past medical history was noncontributory. Physical examination revealed a young male who was visibly distressed secondary to pain. He was afebrile and hemodynamically stable. The abdomen was tender to palpation in the epigastric and right paraumblical region with presence of guarding. There was no rebound tenderness and bowel sounds were present. Remainder of the exam was unremarkable. Laboratory evaluation demonstrated normocytic normochromic anemia (Hct-33), fairly unremarkable blood chemistry and liver function tests. A CT of the abdomen revealed closed loop obstruction with the segment of abnormal bowel extending from the proximal to mid jejunum to the distal ileum. There was a diffuse circumferential irregular wall thickening of the dilated small bowel in the right upper quadrant which could be related to wall edema or mass/neoplasm. There was a 5x3.4x3.4 cm circumscribed mass in the central mesentry with mixed attenuation with some central mesenteric adenopathy. The patient underwent diagnostic laparoscopy and small bowel resection. He was found to have a 5 cm tumor of the proximal small bowel which on pathology was a follicular diffuse large B-cell lymphoma (CD20 positive). The rest of the abdominal exploration was normal with normal small bowel and colon. GI tract is the predominant site of extra-nodal Hodgkin Lymphoma. Both Hodgkin and NHL can involve the GI tract but Hodgkin is very rare. Lymphomas can be primary when they arise in the GI tract and secondary when they involve the GI tract as an extension from another primary source. Predisposing conditions for intestinal lymphoma include autoimmune diseases, immunodeficiency syndromes (e.g. AIDS), long-standing immunosuppressive therapy (e.g. post transplantation), Crohn's disease, radiation therapy and Nodular lymphoid hyperplasia. Contrast radiography is usually the initial diagnostic modality for detecting small bowel lymphomas. IPSID (Immunoproliferative Small Intestinal Disease) associated lymphomas generally appear as a diffuse infiltrating lesion, sometimes resembling cobblestoning and are more common in the proximal small intestine. Western-type non-IPSID lymphomas may appear as ulcerated, protruding, or infiltrating mass lesions and the distal small intestine is the most common site of involvement. Barium enema, Endoscopic Ultrasound and laparotomy are also used for diagnosis.