The patient is a 78-year-old woman whose only reported background of interest is a gastric MALT (mucosa-associated lymphoid tissue) lymphoma that has been in remission for 10 years, following regression related to effective treatment to eradicate a Helicobacter pylori infection.
Came into the Emergency Department due to the appearance of melena 4 days ago, with notable asthenia. Reports that she has had anorexia and progressive weight loss for 4 months. No abdominal pain or altered digestive rhythm.
Physical examination found a notable presence of pale skin and mucosa and a positive rectal examination for melena, with no other pathological data from the examination.
Lab tests: microcytic anaemia with haemoglobin at 7.3 g/dl and albumin at 2.4 g/dl, with no other abnormal results.
• Gastroscopy and colonoscopy: no mucosal abnormalities found.
• Abdominal computed tomography (CT): we observe irregular thickening of the walls of the distal duodenum/proximal jejunum, appearing to be infiltrative, with numerous mesenteric adenopathies (Fig. 1, Fig. 2 and Fig. 3).
Given the suspected infiltrative pathology in the distal duodenum/proximal jejunum, we decided to perform an anterograde single-balloon enteroscopy to evaluate and take biopsies of the suspicious lesions.
Single-balloon enteroscopy (Video 1)
A single-balloon enteroscopy was performed with anaesthetic control and fluoroscopy support, finding nodular, raised and ulcerated lesions of different sizes located in the distal duodenum and proximal jejunum.
Some of the lesions are causing destruction and flattening of the intestinal villi and appear to be infiltrative. Biopsies were taken from the most prominent lesions.
Notable diffuse large B-cell infiltrative lymphocytosis with a high proliferation index was observed, consisting of large-cell lymphocytes (CD20+, Bcl2+, high Ki67 proliferation index). The histological and immunohistochemical study is compatible with high-grade large B-cell non-Hodgkin lymphoma (Fig. 4, Fig. 5, Fig. 6, Fig. 7 and Fig. 8).
Chemotherapy (R-CHOP) treatment was started, with good progress.
SUPPORTING SCIENTIFIC UPDATE
• II.2.2.1. Enterography by computed tomography and magnetic resonance imaging
• II.2.1.2. Enteroscopy
• I.1.4. Balloon enteroscopy
• II.6. Seeking consensus between the different diagnostic and follow-up options for inflammatory bowel disease. Interpretation of the results obtained