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DOI: 10.1055/a-2277-0672
Finding the needle in a haystack: single-balloon enteroscopy to diagnose diffuse large B-cell lymphoma
A 74-year-old woman who was on warfarin for a past medical history of atrial fibrillation and a mechanical mitral valve was admitted with symptomatic anemia. The patient reported fatigue, shortness of breath, and epigastric abdominal pain, with associated black stools for a week. Her physical examination was unremarkable. Laboratory investigations were notable for a normocytic anemia (hemoglobin 6.2 g/dL), with an international normalized ratio (INR) of 1.6 and a prothrombin time of 19.5 seconds. The patient underwent esophagogastroduodenoscopy and colonoscopy, with there being no evidence of active bleeding. She continued to have persistent drops in her hemoglobin requiring several transfusions during her admission. Subsequent video capsule endoscopy revealed blood intermittently in the mid-to-distal small bowel ([Video 1]). Computed tomography with enterography of the abdomen and pelvis revealed no acute intra-abdominal process. Push enteroscopy was subsequently performed, with examination of the jejunum being normal ([Fig. 1]). Further evaluation with single-balloon push enteroscopy revealed an ulcerated lesion of 1 cm, with no active bleeding in the jejunum ([Fig. 2]). The lesion was biopsied, and the rest of the examination was unremarkable. Biopsies showed an infiltrate of large atypical lymphocytes within the lamina propria of the small bowel with architectural destruction and lymphoepithelial lesions ([Fig. 3] a). PAX-5 immunohistochemical staining identified these atypical lymphocytes to be B cells ([Fig. 3] b). The histology and remaining immunohistochemical stains (not shown) were diagnostic of a diffuse large B-cell lymphoma (DLBCL), activated B-cell subtype.
Quality:
DLBCL is the most common type of non-Hodgkin lymphoma [1]. Its presentation may be occult or overt with palpable lymphadenopathy. It may also present at extranodal sites, including the gastrointestinal tract. The stomach and small bowel are the most affected organs. Symptoms of primary gastrointestinal DLBCL include abdominal pain, bowel obstruction, change in bowel habit, or bleeding [2]. Gastrointestinal bleeding can occur during chemotherapy with an incidence up to 11% [2]; however, there are very few reports in the literature of gastrointestinal bleeding as the presenting symptom of DLBCL.
Endoscopy_UCTN_Code_CCL_1AC_2AC
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/).
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Publication History
Article published online:
09 April 2024
© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
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References
- 1 Susanibar-Adaniya S, Barta SK. 2021 Update on diffuse large B cell lymphoma: A review of current data and potential applications on risk stratification and management. Am J Hematol 2021; 96: 617-629 DOI: 10.1002/ajh.26151. (PMID: 33661537)
- 2 Zheng W, Song Y, Lin N. et al. Primary gastrointestinal mantle lymphoma with massive bleeding: A case report and literature review. Chin J Cancer Res 2013; 25: 250-253