Small bowel lymphoma

Case contributed by Dr Ammar Ashraf

Presentation

A heavy smoker presents with epigastric pain and black colored stool for one month.

Patient Data

Age: 40 years
Gender: Male
CT

CT abdomen with oral and IV Contrast after EGD & duodenal ulcer biopsy (CT was done with positive oral contrast because of high clinical suspicion of iatrogenic duodenal perforation).

Scan demonstrates diffuse circumferential mural thickening of the second part of the duodenum. Mild fat stranding is noted around this affected duodenal segment. No evidence of oral contrast leakage is seen from the stomach or duodenum. No free fluid, collection, or pneumoperitoneum is seen. A jejunal bowel loop measuring approximately 6 cm in length showing mild diffuse circumferential thickening and surrounding minimal fat stranding is appreciable in the right lumbar region. Morphology of the remaining oral contrast opacified small bowel loops is within normal limits. No gross pathology is appreciable in the non-prepared colon.  

A well-defined soft tissue density nodule measuring approximately 2.5 x 2.9 cm (average density= 30 HU on plain scan) is noted in the right adrenal gland. The morphology of the remaining abdominal viscera is unremarkable. No significant abdominopelvic lymphadenopathy is seen.

Based on these CT scan features (diffuse circumferential thickening of second part of the duodenum and proximal/mid jejunal loop with mild fat stranding around these affected bowel segments); differential diagnosis of inflammatory bowel disease (Crohn disease),  tuberculosis, or lymphoma was given. Small right adrenal nodule, was likely an incidental benign finding (e.g. lipid poor adenoma), as the patient did not have any clinical or biochemical evidence of adrenal dysfunction.  

Preceding upper endoscopy

Photo

Upper GI endoscopy was done which showed a suspicious malignant looking ulcer in the 1st & 2nd part of the duodenum. Later on, capsule endoscopy was done which showed multiple scattered thickened ulcerated mucosal folds in mid jejunum and proximal ileum with normal intervening mucosa. No active bleeding was seen.   

Case Discussion

Initial biopsy of the duodenal ulcer showed acute and chronic inflammatory changes with pyogenic granuloma formation. AFB & TB cultures were negative.

Based on endoscopic & CT scan findings, repeat biopsy of the duodenal ulcer was done and a diagnosis of CD20 positive diffuse large B-cell lymphoma (DLBCL) was made.

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