S2395 A Series of Unfortunate Events: A Unique Case of Multiple Small Bowel Malignancies in the Setting of Inflammatory Bowel Disease

Abstract

Introduction: Crohn’s disease (CD) is known to increase malignancy risk. Both large and small bowel adenocarcinoma and intestinal carcinoid tumors have been reported at increased rates in patients with CD but rarely concurrently. Additionally, there is an association between Non-Hodgkin Lymphoma and CD, however this is attributed to the use of immunosuppressive medications. We present a patient with a history of follicular lymphoma and ileal CD who later developed two separate small bowel malignancies. Case description/methods: The patient is a 63-year-old male with hypertension, chronic kidney disease, pulmonary embolism, and follicular lymphoma. His follicular lymphoma was diagnosed in 2009 by axillary lymph node biopsy after presenting with lower extremity swelling, night sweats, and weight loss. Staging CT scans prior to treatment demonstrated thickening of the ileum. He was treated with chemotherapy for two years and then remained on maintenance therapy. Five years after diagnosis, the patient was evaluated for 20 years of intermittent diarrhea. Endoscopic evaluation revealed CD of his ileum as well as a duodenal nodule. Elevated serum gastrin and chromogranin A levels, a positive octreotide scan, and EUS fine needle aspiration confirmed the nodule as a stage 1 duodenal carcinoid tumor which was subsequently resected. The following year, he developed fatigue and was noted to have iron deficiency anemia. Repeat EGD and colonoscopy was unrevealing thus he had a video capsule study which demonstrated narrowing of his ileum. CT enteroclysis revealed inflammation in his ileum. He underwent a small bowel resection and surgical pathology confirmed intestinal-type moderately differentiated adenocarcinoma of the ileum. Discussion: This case describes a unique course of a patient with follicular lymphoma and CD developing two small bowel malignancies related to underlying CD. While there are reports of CD developing as a treatment related complication of NHL and NHL developing as a treatment related complication of CD, our patient likely had untreated CD at time of his lymphoma diagnosis. This untreated CD likely led to the development of adenocarcinoma and his carcinoid is also likely associated with his CD. While it is rare to develop multiple small bowel malignancies, this case highlights the importance of maintaining a high index of suspicion of symptom changes in CD patients as they may be indicative of treatment specific and/or CD complications which may ultimately change management.