S2606 Hematochezia as a Rare Presentation of Primary Colonic Diffuse Large B-Cell Lymphoma

Abstract

Introduction: Diffuse large B cell lymphoma is the most common subtype of non-Hodgkin's lymphoma with localization seen only in approximately 20% of patients. Gastrointestinal localization of extranodal disease is extremely rare. We present a case of an 82-year-old female who presented with occult lower gastrointestinal bleeding as the primary presentation leading to the diagnosis of diffuse large B cell lymphoma (DLBCL). Case Description/Methods: An 82-year-old female with a past medical history of partial colectomy with colostomy reversal secondary to diverticulitis presented to the hospital for bright red blood per rectum with the passage of blood clots. She had a negative screening colonoscopy 5 years prior to admission. Upon evaluation, the patient was found to be in hemorrhagic shock resulting from acute blood loss. Colonoscopy and EGD showed mild gastritis, colitis, and a deformed cecum due to previous postoperative changes. Despite packed red blood cell transfusions, the patient remained anemic and developed pancytopenia on hospital day 4. Abdominal CT imaging demonstrated thickened loop of bowel with small to borderline-enlarged mesenteric lymph nodes adjacent to the area of bowel wall thickening. Given her history, lymphadenopathy was considered to be reactive vs. metastatic in nature while biopsies from the colonoscopy were pending. Once hemodynamically stable, the patient was discharged with appropriate f. Final biopsy results of the ascending colon confirmed a diagnosis of diffuse large B cell lymphoma (DLBCL), negative for the t(8;14) translocation or MYC/IGH fusion per FISH analysis. Chemotherapy with cyclophosphamide, vincristine, and prednisolone (CVP) was initiated. Discussion: Although hematochezia in an elderly patient is a cause for malignant workup, it is a rare presentation of hematologic malignancies. Most commonly, extranodal DLBCL is seen to involve the gastric mucosa in the event that the gastrointestinal system is involved at all. Common sites of manifestation include the spleen, thymus, and lymphoid aggregate tissue in the neck. Studies have demonstrated that extranodal disease is correlated with older patient populations as well as a poorer performance score when compared to nodal disease. This case illustrates the need of considering a broad differential inclusive of hematologic malignancy when assessing a patient with lower gastrointestinal bleeding, particularly in elderly patients with associated transfusion-resistant anemia.