Metastatic B-Cell Lymphoma Resulting in Biliary Strictures

Abstract

Stricturing of the biliary tree resulting in jaundice and pancreatitis is an uncommon manifestation of B cell lymphoma. Diagnosing malignant spread with ERCP using brush cytology has been only rarely reported. A 27 year old male presented with a 1 week history of mid-epigastric pain radiating to his flanks bilaterally. The pain was sharp in nature, worse after eating causing nausea and vomiting for 3 days. For several days prior to presentation, he noticed yellowing of his sclera and jaundice. He had no significant past medical history and denied excessive alcohol use. Initial amylase was 194 u/l (28–100 u/l) and lipase 493 u/l (10–60 u/l) with normal serum chemistries and blood count. Total bilirubin was elevated to 11.4 mg/dl (0.1–1.2 mg/dl) as was serum alkaline phosphatase – 161 u/l (30–125 u/l). CT of the abdomen and pelvis showed findings consistent with acute pancreatitis and diffusely enlarged mesenteric lymph nodes. Ultrasound was negative for gallstones, however there was mild dilatation of the common bile duct (CBD) to 7mm. MRI & MRCP were unrevealing for the cause of his jaundice. Upper endoscopy was performed (GIF-140, Olympus America) and showed an ulcerated gastric nodule of which biopsies were taken revealing diffuse large B cell lymphoma. ERCP was performed at an outside institution, and despite multiple attempts, the CBD could not be visualized or cannulated. An ERCP was repeated at our institution several days later which revealed a pancreatic duct (PD) stricture distal to the genu with dilatation of the proximal PD. Additionally, a stricture was seen affecting the distal third of the CBD with proximal dilatation to 2 cm. A sphincterotomy was performed and brushings of the CBD & PD were obtained before placing stents into these ducts. The brushings revealed clusters of neoplastic cells positive for CD-20, diagnosing metastatic spread of B-Cell lymphoma to the biliary tree. Jaundice with stricturing of both the CBD and PD causing ductal dilatation and a double duct sign on ERCP is infrequently seen as the presenting complaint in malignant B cell lymphoma. In addition, it is extremely uncommon to diagnose spread of B-cell lymphoma by brush cytology making this case very unique.