Samia Asif, MD, Lyla Saeed, MD
University of Missouri Kansas City School of Medicine, Kansas City, MO
Introduction: Richter’s Syndrome (RS) is an infrequent complication of chronic lymphocytic leukemia (CLL) involving transformation of CLL into aggressive large-cell lymphoma. Gastrointestinal (GI) involvement with RS is rare, previously described in only 9 case reports in literature. Here we present a unique case of RS manifesting as GI bleed.
Case Description/Methods: A 70-year old male presented with one day history of painless hematochezia. He was diagnosed with CLL four years prior and was currently in remission following chemotherapy. Vitals revealed a blood pressure of 88/35 mmHg and pulse rate of 114/minute. Abdominal exam was unremarkable. Rectal exam showed blood in the vault. Work-up showed a hemoglobin of 4.8 g/dl and white cell count of 5300/microliter. Coagulation profile was normal. After initial resuscitation, an esophagogastroduodenoscopy (EGD) was performed showing an excavated lesion with minimal oozing in second part of duodenum; biopsy was obtained and endoclip was applied. Colonoscopy showed blood in terminal ileum and throughout the colon. Capsule study revealed scattered erosions and ulcers with hemorrhage in the jejunum and active bleeding from the distal ileum. Urgent tagged red-cell scan was obtained followed by coil embolization of a focus of brisk active extravasation arising from a terminal ileal branch of ileocolic artery by Intervention Radiology (IR). Duodenal biopsy demonstrated lymphocytic infiltrate consistent with his history of CLL with a background of larger lymphocytes concerning for Richter’s transformation to diffuse large B-cell lymphoma (DLBCL). Computed Tomography (CT) abdomen/pelvis showed splenomegaly and diffuse abdominal and pelvic lymphadenopathy. Pathology report of an excisional biopsy of left axillary lymph node confirmed Richter’s transformation to DLBCL. Systemic chemotherapy and immunotherapy was initiated. GI bleed resolved few days into chemotherapy.
Discussion: Patients with prior history of hematological malignancies presenting with GI symptoms such as nausea/vomiting, intestinal obstruction, acute perforation or GI bleed should be evaluated for recurrence. In addition to imaging, a low threshold for invasive work-up such as EGD or colonoscopy with biopsy of any lesions seen may be necessary for timely initiation of therapy. This case demonstrates that evaluation for etiology in each case of GI bleed has to be individualized. Identifying the correct diagnosis is the key to successful patient treatment.
Citation: Samia Asif, MD, Lyla Saeed, MD. P0435 - A MALIGNANT CASE OF GASTROINTESTINAL BLEED. Program No. P0435. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.