ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI A Rare Cause of Intermittent Epigastric Pain and Melena in a 38-Year-Old Man Pao-Ying Lin,1,3 Jia-Ruey Tsai,2,3 and Chun-Chao Chang1,3 1 3
Division of Gastroenterology & Hepatology, 2Division of Hematology & Oncology, Department of Internal Medicine, and Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
Question: A 38-yearold man presented with a 1-month history of intermittent epigastric pain and melena. He denied hematemesis, fever, and body weight loss. The only significant past medical history were hypertension and gallstones. Physical examination showed epigastric tenderness without Murphy’s sign. His initial blood tests including hemoglobin level and lactate dehydrogenase were unremarkable. Upper gastrointestinal (UGI) endoscopy illustrated some ulcerated, doughnut-shaped tumors involving gastric body and fundus (Figure A). Endoscopic ultrasonography (EUS) demonstrated gastric wall thickening of 7.4 mm (Figure B). Abdominal CT showed focal gastric wall thickening (Figure C), enlarged lymph nodes, and small bowel intussusception (Figure D) without obstruction. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.09.043
Gastroenterology 2015;148:e10–e11
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 5: Gastric Burkitt’s Lymphoma
Subsequent blood tests showed positive human immunodeficiency virus serology and viral load of 126,281 copies per milliliter. Histologic examination of the gastric biopsy specimen displayed diffuse proliferation of medium-sized, atypical lymphoid cells, and high mitotic activity. Immunohistochemical stains were positive for CD20 (Figure E), BCL-6 (B-cell lymphoma 6; Figure F), and CD10 (Figure G). Almost all cells were high mitotic figures of Ki-67 95% (Figure H) and 30% positive signals cells in Epstein-Barr virus–encoded RNA. Fluorescence in situ hybridization confirms MYC translocation. Helicobacter pylori was not present in the hematoxylin and eosin stain. These findings were consistent with Burkitt’s lymphoma (BL). Our patient received chemotherapy with dose-adjusted R-EPOCH (rituximab, etoposide, prednisolone, vincristine, cyclophosphamide, and doxorubicin) concomitant with highly active antiretroviral therapy. UGI endoscopy and EUS 4 months later revealed only ulcer scar and normal thickening of gastric mucosa (Figure I). BL is a rare and highly aggressive B-cell non-Hodgkin lymphoma. There are 3 variants of BL: endemic, sporadic, and immunodeficiency associated—among them, the sporadic type is the most common. The GI tract is the most common extranodal sites; frequent sites are the stomach followed by small and large intestines.1,2 Gastric BL patients present with abdominal pain and palpable mass, weight loss, GI bleeding, intussusception, and intestinal obstruction.2 Acute GI bleeding in AIDS patients may be owing to peptic ulcer disease, opportunistic infections caused by cytomegalovirus, herpes simplex, and Candida or tumor related, such as Kaposi sarcoma and non-Hodgkin lymphoma. The bleeding risk is inversely proportional to the CD4 count.3 UGI endoscopy and EUS with fine needle aspiration biopsy are the most indispensable modalities to confirm an accurate diagnosis.2 EUS can detect not only the depth of tumor infiltration, but also the existence of perigastric lymph nodes, and thereby can provide complementary information for treatment plans.2 The most important prognostic factors include old age, poor performance status, high lactate dehydrogenase concentration, involvement to the central nervous system or bone marrow, and advanced tumor stage.1
References 1. 2. 3.
Jang SJ, Yoon DH, Kim S, et al. A unique pattern of extranodal involvement in Korean adults with sporadic Burkitt lymphoma: a single center experience. Ann Hematol 2012;91:1917–1922. Ghimire P, Wu GY, Zhu L, et al. Primary gastrointestinal lymphoma. World J Gastroenterol 2011;17:697–707. Bini EJ, Micale PL, Weinshel EH, et al. Risk factors for rebleeding and mortality from acute upper gastrointestinal hemorrhage in human immunodeficiency virus infection. Am J Gastroenterol 1999;94:358–363.
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Division of Gastroenterology & Hepatology, 2Division of Hematology & Oncology, Department of Internal Medicine, and Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
Question: A 38-yearold man presented with a 1-month history of intermittent epigastric pain and melena. He denied hematemesis, fever, and body weight loss. The only significant past medical history were hypertension and gallstones. Physical examination showed epigastric tenderness without Murphy’s sign. His initial blood tests including hemoglobin level and lactate dehydrogenase were unremarkable. Upper gastrointestinal (UGI) endoscopy illustrated some ulcerated, doughnut-shaped tumors involving gastric body and fundus (Figure A). Endoscopic ultrasonography (EUS) demonstrated gastric wall thickening of 7.4 mm (Figure B). Abdominal CT showed focal gastric wall thickening (Figure C), enlarged lymph nodes, and small bowel intussusception (Figure D) without obstruction. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.09.043
Gastroenterology 2015;148:e10–e11
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 5: Gastric Burkitt’s Lymphoma
Subsequent blood tests showed positive human immunodeficiency virus serology and viral load of 126,281 copies per milliliter. Histologic examination of the gastric biopsy specimen displayed diffuse proliferation of medium-sized, atypical lymphoid cells, and high mitotic activity. Immunohistochemical stains were positive for CD20 (Figure E), BCL-6 (B-cell lymphoma 6; Figure F), and CD10 (Figure G). Almost all cells were high mitotic figures of Ki-67 95% (Figure H) and 30% positive signals cells in Epstein-Barr virus–encoded RNA. Fluorescence in situ hybridization confirms MYC translocation. Helicobacter pylori was not present in the hematoxylin and eosin stain. These findings were consistent with Burkitt’s lymphoma (BL). Our patient received chemotherapy with dose-adjusted R-EPOCH (rituximab, etoposide, prednisolone, vincristine, cyclophosphamide, and doxorubicin) concomitant with highly active antiretroviral therapy. UGI endoscopy and EUS 4 months later revealed only ulcer scar and normal thickening of gastric mucosa (Figure I). BL is a rare and highly aggressive B-cell non-Hodgkin lymphoma. There are 3 variants of BL: endemic, sporadic, and immunodeficiency associated—among them, the sporadic type is the most common. The GI tract is the most common extranodal sites; frequent sites are the stomach followed by small and large intestines.1,2 Gastric BL patients present with abdominal pain and palpable mass, weight loss, GI bleeding, intussusception, and intestinal obstruction.2 Acute GI bleeding in AIDS patients may be owing to peptic ulcer disease, opportunistic infections caused by cytomegalovirus, herpes simplex, and Candida or tumor related, such as Kaposi sarcoma and non-Hodgkin lymphoma. The bleeding risk is inversely proportional to the CD4 count.3 UGI endoscopy and EUS with fine needle aspiration biopsy are the most indispensable modalities to confirm an accurate diagnosis.2 EUS can detect not only the depth of tumor infiltration, but also the existence of perigastric lymph nodes, and thereby can provide complementary information for treatment plans.2 The most important prognostic factors include old age, poor performance status, high lactate dehydrogenase concentration, involvement to the central nervous system or bone marrow, and advanced tumor stage.1
References 1. 2. 3.
Jang SJ, Yoon DH, Kim S, et al. A unique pattern of extranodal involvement in Korean adults with sporadic Burkitt lymphoma: a single center experience. Ann Hematol 2012;91:1917–1922. Ghimire P, Wu GY, Zhu L, et al. Primary gastrointestinal lymphoma. World J Gastroenterol 2011;17:697–707. Bini EJ, Micale PL, Weinshel EH, et al. Risk factors for rebleeding and mortality from acute upper gastrointestinal hemorrhage in human immunodeficiency virus infection. Am J Gastroenterol 1999;94:358–363.
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