Mukarram Amine, DO, Amit Srivastava, MD
Loyola MacNeal Hospital, Berwyn, IL
Introduction: Only 5-10% of gastrointestinal bleeding is from the small intestine, and in these cases, video capsule endoscopy (VCE) is considered as a first line procedure for small bowel investigation. The most common causes of small intestinal bleeding in patients older than 40 years include angioectasias and NSAID-induced ulcers. In younger patients, its is more common to see bleeding events as a result of Crohn disease, Meckel diverticula, Dieulafoy lesions, and tumors. Celiac disease can cause bleeding in both age groups. Our case reports on an uncommon presentation of a rare gastrointestinal malignancy, and the utility of push enteroscopy in the diagnosis thereof.
Case Description/Methods: A 77 year old female with a past medical history of gastric carcinoid, iron deficiency anemia, and history of pulmonary embolism now on rivaroxaban had presented after a syncopal episode. Upon review of systems, the patient did report dark stools, which she attributed to her iron pills. On presentation, the patient was found to have severe iron deficiency anemia and heme-positive stools. EGD and colonoscopy were performed, which did not reveal an active source of bleeding. She was taken off of rivaroxaban and her hemoglobin subsequently stabilized and she had no further episodes of melena. She was discharged with instructions to follow up for an outpatient VCE. Ten days later, before the scheduled VCE, the patient returned to the hospital with another episode of melena, and was again found to have a substantial decline in her hemoglobin. The patient then underwent push enteroscopy, which revealed multiple actively bleeding, cratered ulcers ranging in size from 10mm to 20mm in the distal duodenum and proximal jejunum which were endoscopically ablated. Biopsy of these ulcers was positive for non-germinal center derived diffuse large B-cell lymphoma. The patient was subsequently transferred to a tertiary care center for further staging and possible treatment.
Discussion: This case demonstrates the utility of push enteroscopy for both diagnosis and treatment in clinically significant, obscure, occult gastrointestinal bleeds. In this patient in particular, it also enabled the early diagnosis of a rare and morbid malignancy for which survival without treatment is measured in months. While small bowel tumors are among the most common causes of obscure GI bleed in young patient, this is a rare finding in the elderly. As this case demonstrates though, the possibility of malignancy should not be overlooked.
Citation: Mukarram Amine, DO, Amit Srivastava, MD. P2266 - PUSH ENTEROSCOPY IN THE DIAGNOSIS OF A GASTROINTESTINAL BLEED CAUSED BY DIFFUSE LARGE B-CELL LYMPHOMA. Program No. P2266. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.