S2800 B-cell Lymphoma of the Small Bowel: Common Presentations of an Uncommon Disease

Abstract

INTRODUCTION: The gastrointestinal (GI) tract is the most common site of extra nodal involvement of lymphoma; the most prevalent histopathological type is diffuse large B-cell lymphoma [1,3]. Primary GI lymphomas are rare, making up 1%–4% of all GI malignancies [2]. Here we discuss three different clinical presentations and endoscopic appearances of B-Cell lymphoma of the duodenum. CASE DESCRIPTION/METHODS: Case 1: An 83-year-old female with a history of cholecystectomy presented for endoscopy (EGD) after admission for abdominal pain and weight loss. EGD showed mucosa in the distal duodenal bulb with narrowing and pathology was significant for moderate chronic active duodenitis with villous. Four months later, the patient had a repeat EGD for right upper quadrant pain which again showed benign appearing mild stenosis the duodenal bulb that was traversed and dilated to 15mm, as well as nodularity and scalloping in the second portion of the duodenum (Figure 1). Biopsy showed Small B-Cell Lymphoid Neoplasm with plasmacytic differentiation. Case 2: A 67-year-old male with no medical history was referred to the gastrointestinal clinic for evaluation of reflux disease after presenting to the ER with burning chest pain. Patient underwent EGD which showed diffuse mucosal with white scattered nodules in the second portion of the duodenum (Figure 2). Pathology showed follicular lymphoma. Case 3: A 58-year-old man with a history of obscure gastrointestinal bleeding presented with two episodes of black stools. CT Abdomen/Pelvis demonstrated mesenteric lymphadenopathy measuring up to 1.2 cm with adjacent inflammatory process; capsule endoscopy showed jejuno-iileitis. Push Enteroscopy showed a clean based 1.2 cm ulcer (Figure 3) and a raised white about 1.2 cm in size with central ulceration in the jejunum. Jejunal ulcer pathology showed low grade B cell lymphoma and the white plaque was significant for atypical lymphoid infiltrate consistent with duodenal type follicular lymphoma. DISCUSSION: The three cases all share a diagnosis of B-Cell lymphoma but each case presented with unique symptoms and distinctive endoscopic findings. Small bowel lymphomas can be categorized into three main types and the clinical presentation varies based on this. Two of the cases presented are follicular lymphomas which are categorized as western-type non-immunoproliferative small intestinal disease (IPSID). One case was highly suggestive of extra nodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT) which is categorized as IPSID.Figure 1.: Benign appearing mild stenosis of the duodenal bulb that was traversed and dilated to 15 mm, as well as nodularity and scalloping in the second portion of the duodenum.Figure 2.: Diffuse mucosal changes with white scattered nodules in the second portion of the duodenum.Figure 3.: Clean based 1.2 cm ulcer.