INTRODUCTION: The gastrointestinal (GI) tract is a well-known site for extranodal lymphoma involvement, representing 30-40% of lymphomas. The stomach is known to be the most common site followed by small intestine and colorectum. The development of chronic liver disease and cirrhosis in patients with pre-existing lymphoproliferative disorder has been well described. However, the development of lymphoma in subjects with cirrhosis is rare. CASE DESCRIPTION/METHODS: We report a 55-year-old male history of alcoholic decompensated cirrhosis with ascites, and esophageal varices, presented with two weeks of epigastric abdominal pain and worsening ascites.Labs remarkable for Hb 9.1 gm/dl, INR 2.0, ALT 44 IU/ml, AST 67 IU/ml, ALP 253 mg/dl, bilirubin 5.2 mg/dl and normal AFP. ABD CT scan demonstrates mild gastric wall thickening, cirrhosis, moderate ascites, and multiple new hypodense liver lesions.The lesions were classified as an intermediate probability for HCC based on the LI-RADS classification system (LI RADS 3) (figure A/B).Due to the CT findings in the setting of cirrhosis, a provisional diagnosis of HCC was made.Upper endoscopy EGD demonstrates medium non-bleeding esophageal varices and multiple new umbilicated, ulcerated, firm, submucosal nodules throughout the gastric body(figure C).Biopsy of the submucosal nodule revealed high-grade B-cell lymphoma (HGBL) involving the lamina propria, without Helicobacter Pylori. Neoplastic cells were positive for CD20, Pax-5, BCL-6, CD10, BCL-2, 95% positive for lymphoma cells (figure D). Targeted biopsy of the liver lesions demonstrates similar cell morphology and immunostaining profile confirming the diagnosis of metastatic diffuse B-cell lymphoma (DBCL) (Figure E). DISCUSSION: PGL constitutes < 5% of all primary gastric neoplasms. The incidence of DBCL in cirrhosis is extremely rare. HBV and H. pylori have been postulated to cause chronic antigenic stimulation resulting in dysregulation in immune function leading to monoclonal gammopathy and malignant lymphoproliferative disease. Presentation of PGL is nonspecific ranging from abdominal pain, weight loss, GI bleeding, and rarely GI perforation. DBCL can be localized to the stomach or have distant metastasis involving the liver.These hepatic lesions lack the radiologic characteristic of HCC such as arterial enhancement, pseudo capsule, and washout further supporting diagnosis of lymphoma. Metastatic PGL can mimick HCC in cirrhosis and will require targeted liver biopsy to make diagnosis.Figure A/B.: Cross sectional imaging A-arterial phase. B-portal venous phase.Figure C.: EGD image of umbilicated mucosal gastric lesions.Figure D.: Gastric lesion biopsy. Figure E: Targeted liver lesion biopsy showing lymphoma cells similar in morphology to stomach biopsy D.