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An Unusual Presentation of Small Bowel Lymphoma
The Journal of Emergency Medicine, Vol. 41, No. 5, pp. 531–533, 2011 Copyright © 2011 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter
doi:10.1016/j.jemermed.2009.04.067
Visual Diagnosis in Emergency Medicine
AN UNUSUAL PRESENTATION OF SMALL BOWEL LYMPHOMA Ahmed N. Assar,
MD, FRCS (GLASG.)
Department of General Surgery, Luton & Dunstable Hospital NHS Trust, Luton, Bedfordshire, UK Reprint Address: Ahmed N. Assar, MD, FRCS (GLASG.), Stanford University Medical Center, Clark Center, 318 Campus Drive West E350, Stanford, CA 94305-5431
INTRODUCTION
sided groin mass measuring approximately 15 cm in diameter (Figure 1). This mass extended proximally into the right lower quadrant (RLQ) and distally into the right thigh. It was fluctuant and the overlying skin was erythematous, hot, and tender. Abdominal examination revealed mild RLQ fullness, with no tenderness, masses, or rigidity. The bowel sounds were active and the rectal examination was unremarkable. The patient was admitted to the hospital to undergo further investigations. Laboratory tests showed mild leukocytosis of 12,000/ mm3, hemoglobin of 11.4 g/dL, and C-reactive protein of 311 mg/L (normal range: 0 – 8 mg/L). The serum chemistry panel was normal. An abdominal computed tomography (CT) scan revealed a soft tissue mass measuring 12 cm ⫻ 12 cm ⫻ 23 cm that occupied the right side of the pelvis (Figure 2) and extended into the right inguinal region (Figure 3). Given these findings, the diagnosis of a right groin abscess, with possible intra-abdominal communication, was made. Under general anesthesia, incision of the abscess revealed a large amount of fecal fluid emerging through the wound. Consequently, a laparotomy was performed that revealed a perforation of the terminal ileum (Figure 4) causing a retroperitoneal abscess, and a limited right hemicolectomy was done. Histological examination showed a diffuse large Bcell ileal lymphoma, and a bone marrow biopsy showed no infiltration by lymphoma cells. The patient was then commenced on chemotherapy and discharged from the hospital; however, he was soon re-admitted with an enterocutaneous fistula that ultimately was treated surgi-
The gastrointestinal tract is the most common site of primary extranodal non-Hodgkin’s lymphoma, a term used to describe lymphoma that arises from any organ or tissue other than the lymph nodes or the spleen (1). Small bowel lymphoma most commonly affects the ileum, followed by the jejunum and the duodenum (2). Gastrointestinal lymphomas usually present with intermittent abdominal pain, diarrhea, weight loss, and occasionally, fever. However, small bowel lymphoma may present with acute surgical emergencies such as small bowel obstruction or perforation (3). This article reports the unusual presentation of small bowel lymphoma as a groin abscess due to a perforation in the terminal ileum.
CASE REPORT A 50-year-old man presented to the Emergency Department (ED) with a 6-month history of right groin swelling that recently had become more painful. The patient reported some recent weight loss and reduced appetite but denied any fever, abdominal pain, or a change in bowel habits. On physical examination, the patient was not in distress. His vital signs were: temperature 38°C, heart rate 84 beats/min, blood pressure 125/85 mm Hg, and respiratory rate 22 breaths/min. There was an obvious right-
RECEIVED: 15 November 2008; FINAL ACCEPTED: 16 April 2009
SUBMISSION RECEIVED:
3 February 2009;
531
532
A. N. Assar
Figure 3. Abdominal computed tomography scan showing extension of the mass (arrows) into the right inguinal region.
Small bowel tumors account for 1–2% of all gastrointestinal neoplasms and are usually misdiagnosed or diagnosed late (3,4). Patients with small bowel tumors usually present with non-specific symptoms such as intermittent abdominal pain, diarrhea, weight loss, or
chronic anemia. Such symptoms are often overlooked by the physician or ignored by the patient, resulting in a delayed diagnosis, sometimes up to a few months (3– 6). Small bowel lymphoma is the third most common malignant tumor of the small bowel (4). This tumor may present with small bowel obstruction or perforation, requiring an emergent laparotomy in up to 30 –50% of patients (5). In this report, a 50-year-old-man presented with a 6-month history of a groin swelling that initially was thought to be a groin abscess, but was found at laparotomy to result from a perforated small bowel lymphoma. The patient’s associated non-specific symptoms of weight loss and reduced appetite, in addition to the underlying cause of his presentation (bowel perforation), are characteristic of small bowel lymphoma (3).
Figure 2. Abdominal computed tomography scan showing a soft tissue mass (arrows) involving the right side of the pelvis.
Figure 4. Intraoperative image showing perforation of the terminal ileum (arrow). Note the proximity to the cecum (arrow head).
Figure 1. Preoperative image showing the right groin abscess extending into the thigh (arrows).
cally. Despite a complicated postoperative recovery, the patient is alive and well 1 year after presentation.
DISCUSSION
An Unusual Presentation of Small Bowel Lymphoma
This case of small bowel lymphoma demonstrates the unusually long duration of symptoms and the unusual presentation a patient with this tumor can have. More importantly, however, this case also shows that a simple groin abscess, which might be dealt with in the ED, may not be such a simple matter because a patient may harbor a much more serious underlying condition. An intraabdominal source of infection should be considered in the differential diagnosis of a groin abscess, particularly in a patient with long-standing symptoms and no identifiable external source of infection. Early surgical consultation and sensitive abdominal imaging tests, such as CT scan, constitute reasonable early management steps in such cases.
533
REFERENCES 1. Psyrri A, Papageorgiou S, Economopoulos T. Primary extranodal lymphomas of stomach: clinical presentation, diagnostic pitfalls and management. Ann Oncol 2008;19:1992–9. 2. Yin L, Chen CQ, Peng CH, et al. Primary small-bowel non-Hodgkin’s lymphoma: a study of clinical features, pathology, management and prognosis. J Int Med Res 2007;35:406 –15. 3. Gill SS, Heuman DM, Mihas AA. Small intestinal neoplasms. J Clin Gastroenterol 2001;33:267– 82. 4. Hatzaras I, Palesty JA, Abir F, et al. Small-bowel tumors: epidemiologic and clinical characteristics of 1260 cases from the Connecticut tumor registry. Arch Surg 2007;142:229 –35. 5. Ciresi DL, Scholten DJ. The continuing clinical dilemma of primary tumors of the small intestine. Am Surg 1995;61:698 –702. 6. Baillie CT, Williams A. Small bowel tumours: a diagnostic challenge. J R Coll Surg Edinb 1994;39:8 –12.
doi:10.1016/j.jemermed.2009.04.067
Visual Diagnosis in Emergency Medicine
AN UNUSUAL PRESENTATION OF SMALL BOWEL LYMPHOMA Ahmed N. Assar,
MD, FRCS (GLASG.)
Department of General Surgery, Luton & Dunstable Hospital NHS Trust, Luton, Bedfordshire, UK Reprint Address: Ahmed N. Assar, MD, FRCS (GLASG.), Stanford University Medical Center, Clark Center, 318 Campus Drive West E350, Stanford, CA 94305-5431
INTRODUCTION
sided groin mass measuring approximately 15 cm in diameter (Figure 1). This mass extended proximally into the right lower quadrant (RLQ) and distally into the right thigh. It was fluctuant and the overlying skin was erythematous, hot, and tender. Abdominal examination revealed mild RLQ fullness, with no tenderness, masses, or rigidity. The bowel sounds were active and the rectal examination was unremarkable. The patient was admitted to the hospital to undergo further investigations. Laboratory tests showed mild leukocytosis of 12,000/ mm3, hemoglobin of 11.4 g/dL, and C-reactive protein of 311 mg/L (normal range: 0 – 8 mg/L). The serum chemistry panel was normal. An abdominal computed tomography (CT) scan revealed a soft tissue mass measuring 12 cm ⫻ 12 cm ⫻ 23 cm that occupied the right side of the pelvis (Figure 2) and extended into the right inguinal region (Figure 3). Given these findings, the diagnosis of a right groin abscess, with possible intra-abdominal communication, was made. Under general anesthesia, incision of the abscess revealed a large amount of fecal fluid emerging through the wound. Consequently, a laparotomy was performed that revealed a perforation of the terminal ileum (Figure 4) causing a retroperitoneal abscess, and a limited right hemicolectomy was done. Histological examination showed a diffuse large Bcell ileal lymphoma, and a bone marrow biopsy showed no infiltration by lymphoma cells. The patient was then commenced on chemotherapy and discharged from the hospital; however, he was soon re-admitted with an enterocutaneous fistula that ultimately was treated surgi-
The gastrointestinal tract is the most common site of primary extranodal non-Hodgkin’s lymphoma, a term used to describe lymphoma that arises from any organ or tissue other than the lymph nodes or the spleen (1). Small bowel lymphoma most commonly affects the ileum, followed by the jejunum and the duodenum (2). Gastrointestinal lymphomas usually present with intermittent abdominal pain, diarrhea, weight loss, and occasionally, fever. However, small bowel lymphoma may present with acute surgical emergencies such as small bowel obstruction or perforation (3). This article reports the unusual presentation of small bowel lymphoma as a groin abscess due to a perforation in the terminal ileum.
CASE REPORT A 50-year-old man presented to the Emergency Department (ED) with a 6-month history of right groin swelling that recently had become more painful. The patient reported some recent weight loss and reduced appetite but denied any fever, abdominal pain, or a change in bowel habits. On physical examination, the patient was not in distress. His vital signs were: temperature 38°C, heart rate 84 beats/min, blood pressure 125/85 mm Hg, and respiratory rate 22 breaths/min. There was an obvious right-
RECEIVED: 15 November 2008; FINAL ACCEPTED: 16 April 2009
SUBMISSION RECEIVED:
3 February 2009;
531
532
A. N. Assar
Figure 3. Abdominal computed tomography scan showing extension of the mass (arrows) into the right inguinal region.
Small bowel tumors account for 1–2% of all gastrointestinal neoplasms and are usually misdiagnosed or diagnosed late (3,4). Patients with small bowel tumors usually present with non-specific symptoms such as intermittent abdominal pain, diarrhea, weight loss, or
chronic anemia. Such symptoms are often overlooked by the physician or ignored by the patient, resulting in a delayed diagnosis, sometimes up to a few months (3– 6). Small bowel lymphoma is the third most common malignant tumor of the small bowel (4). This tumor may present with small bowel obstruction or perforation, requiring an emergent laparotomy in up to 30 –50% of patients (5). In this report, a 50-year-old-man presented with a 6-month history of a groin swelling that initially was thought to be a groin abscess, but was found at laparotomy to result from a perforated small bowel lymphoma. The patient’s associated non-specific symptoms of weight loss and reduced appetite, in addition to the underlying cause of his presentation (bowel perforation), are characteristic of small bowel lymphoma (3).
Figure 2. Abdominal computed tomography scan showing a soft tissue mass (arrows) involving the right side of the pelvis.
Figure 4. Intraoperative image showing perforation of the terminal ileum (arrow). Note the proximity to the cecum (arrow head).
Figure 1. Preoperative image showing the right groin abscess extending into the thigh (arrows).
cally. Despite a complicated postoperative recovery, the patient is alive and well 1 year after presentation.
DISCUSSION
An Unusual Presentation of Small Bowel Lymphoma
This case of small bowel lymphoma demonstrates the unusually long duration of symptoms and the unusual presentation a patient with this tumor can have. More importantly, however, this case also shows that a simple groin abscess, which might be dealt with in the ED, may not be such a simple matter because a patient may harbor a much more serious underlying condition. An intraabdominal source of infection should be considered in the differential diagnosis of a groin abscess, particularly in a patient with long-standing symptoms and no identifiable external source of infection. Early surgical consultation and sensitive abdominal imaging tests, such as CT scan, constitute reasonable early management steps in such cases.
533
REFERENCES 1. Psyrri A, Papageorgiou S, Economopoulos T. Primary extranodal lymphomas of stomach: clinical presentation, diagnostic pitfalls and management. Ann Oncol 2008;19:1992–9. 2. Yin L, Chen CQ, Peng CH, et al. Primary small-bowel non-Hodgkin’s lymphoma: a study of clinical features, pathology, management and prognosis. J Int Med Res 2007;35:406 –15. 3. Gill SS, Heuman DM, Mihas AA. Small intestinal neoplasms. J Clin Gastroenterol 2001;33:267– 82. 4. Hatzaras I, Palesty JA, Abir F, et al. Small-bowel tumors: epidemiologic and clinical characteristics of 1260 cases from the Connecticut tumor registry. Arch Surg 2007;142:229 –35. 5. Ciresi DL, Scholten DJ. The continuing clinical dilemma of primary tumors of the small intestine. Am Surg 1995;61:698 –702. 6. Baillie CT, Williams A. Small bowel tumours: a diagnostic challenge. J R Coll Surg Edinb 1994;39:8 –12.