Case No. :	49
Month :	January
Year :	2003
Contributor :	Dr. Ashish Wasnik

Other Cases

A 35-year-old man presented with history of loss of weight and appetite for the past three months. He had dull aching pain in the periumbilical region radiating to left lumbar region for two months and abdominal distension since one month. There was no history of fever or tuberculosis or tuberculosis contact in the past.

On examination, there was a non tender, ill defined, immobile lump in the left lumbar region.

The hemoglobin of 12.6 gm% , ESR of 43 mm at the end of the first hour. His HIV test was non reactive and chest radiograph was normal.

RADIOLOGICAL FINDINGS:

A small bowel series was done which showed a dilated loop of jejunum extending from theduodeno-jejunal flexure to a length of 10-12 cm distally with irregularity of the mucosal pattern and intermittent narrowing in the involved segment (Fig 1).

Fig.1

The dilated loop appeared to be fixed in the left lumbar region. A differential diagnosis of lymphoma or tuberculosis of the small bowel was made and ultrasonogram and CT of the abdomen was advised.

Ultrasonogram of the abdomen revealed a mass in the jejunum with dilatation of the jejunum with thickening of the jejunal wall of approximately 1.23cm with dilatation of the third part of the duodenum (Fig 2). Enlarged mesenteric lymph nodes were noted.

Fig.2

CT abdomen showed marked dilatation of the jejunal loops with a circumferential wall thickening of 1 cm which showed minimal enhancement on the contrast injection. Abdominal lymphadenopathy (Fig 3, 4, 5,6)

Fig.3	Fig.4
Fig.5	Fig.6

An ultrasound guided biopsy of the jejunal mass was done, the histopathology of which revealed it to be Non Hodgkins Lymphoma.

DIFFERENTIAL DIAGNOSIS:

Small bowel tuberculosis: Ileocecal involvement is common. Adhesions are usual and varying degrees of ascites or loculated fluid is present. Stictures are associatedw with wall thickening. Mesenteric lmphadenopathy is common.

Crohn's disease: There are 'long' ulcers, The terminal ileum is more often more affected; skip areas and eccentric strictures are characteristic.

Adenocarcinoma : This shows a local, short segment stricture with mass effect.

Nodular lymphoid hyperplasia is characterized by small evenly distributed nodules of uniform size.

In view of the overlap of the radiological findings, a confirmatory biopsy is often required.

DISCUSSION:

Small bowel lymphomas constitute 20% of the primary malignancies of the small bowel with an incidence of about 0.12 per 100,000 population with the commonest site being ileum. It is seen most commonly after 20years of age.

The predisposing factors are celiac disease, immunological dysfunction and chronic lymphoid leukemia.

The presentation is usually chronic with abdominal pain, diarrhea, weight loss, intestinal bleeding and, at times, a palpable mass.

The diagnostic criteria for primary intestinal lymphoma are:-

1)No palpable superficial lymph nodes.

2)Chest radiograph - normal.

3)No abnormality in TLC/DLC.

4)Alimentary tract lesion with lymph node involvement.

5)No involvement of liver/spleen.

The patterns of small bowel lymphoma can be divided into:

1. Infiltrative - which shows a circumferential involvement of a variable length of the of the small bowel with thickening and effacement of folds and widening of the lumen rather than narrowing. This is due to the infilteration of muscularis and destruction of the autonomic nervous system and at times the bowel might give way causing aneurysmal dilatation - mostly of the antimesentric segment.

2. Nodular lesions - which are usually larger, variable in size & irregular in distribution.

3. Polypoidal - which may cause intussusception.

4. Endoexoenteric - known to cause fistulas.

The classical findings on various radiological modalities are :

1. The small bowel series shows a luminal narrowing of the involved segment with loss of mucosal pattern and thickening of the valvulae conniventes and intraluminal filling defects - at times with dilatation of the involved segment.

2. Ultrasonogram shows a very hypoechoic lesion with no wall layer definition and presence of abdominal lymphadenopathy.

3. CT scan shows a sausage shaped mass of relatively homogenous tissue density and asymmetric wall thickening of usually more than two centimeter with aneurysmal dilatation in some cases or polypoidal mass along with abdominal lymphadenopathy.

The confirmatory diagnosis is based on histopathological examination of the biopsy from the lesion.

Treatment:- The treatment of lymphoma is surgery or chemotherapy.

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