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Transcript
Abstract Number: 106
RARE COEXISTENCE OF SMALL
BOWEL LYMPHOMA WITH
TUBERCULOSIS IN A YOUNG
PATIENT
PATIENT HISTORY
• 22 year old male came with history of colicky,
non radiating abdominal pain which was
progressive in nature for 1 year with loss of
appetite and loss of weight.
• Melena for 6 months, vomiting for 3 months
and low grade fever for 3 days.
ON EXAMINATION
• A mass was palpable in the umbilical and
epigastric region
• Firm to hard in consistency
• Well defined borders
• Was less prominent on leg raising
• Mass was dull on percussion
LAB PARAMETERS
• Hb-11.4
• TC-11800
• DC
N-71
L-25
E-04
ESR-110
UREA -26
CREATININE-0.7
NA+=128
K+=4.20
RBS-98.
ALBUMIN-3.7
GLOBULIN-2.3
A/G RATIO-1.6
•
•
•
•
SER LIPASE-40
DIR BILI-0.1
SER AMYLASE-80
TOT BILIRUBIN-0.5
INDIRECT BILI-0.4
ALP-123. TOT PROTIEN-6.0
ULTRASOUND ABDOMEN
• Small bowel loop showed circumferential
bowel wall thickening.
• Dilated and thickened small
bowel loop with luminal
narrowing
SCANOGRAM - ABDOMEN
• Scanogram
shows dilated
small bowel
loops.
CECT ABDOMEN
• Long segment bowel wall thickening involving ilieal
loops in the infra umbilical region for a length of
20cms with maximal wall thickness of 20mm.
• Dilatation of short segment of bowel loops proximal to
the thickened bowel was seen.
• Irregularly marginated soft tissue density lesion with
necrotic areas and foci of air noted in the mesentery in
the umbilical region abutting the thickened bowel wall.
• Multiple mesenteric nodes, largest measuring ~12mm
were noted adjacent to the thickened bowel.
AXIAL CECT ABDOMEN
CORONAL CECT ABDOMEN
SAGITTAL CECT ABDOMEN
DIFFERENTIAL DIAGNOSIS
• Differential diagnosis of
- Lymphoma
- Carcinoid
- Adenocarcinoma
were considered according to CT/CECT findings.
SURGICAL MANAGEMENT
• Patient was taken up for surgery and intra-operatively
a mass was noted in the distal ilieal mesentery
compressing the ileum 15cm from the ileocaecal valve.
• Adjacent bowel wall thickening was noted.
• Post surgically, differential diagnosis of
1.Adenocarcinoma small bowel
2.TB small bowel.
3.Lymphoma small bowel.
4.Regional ileitis.
were considered by the surgeons.
SURGICAL MANAGEMENT
HISTOPATHOLOGY
• Histopathology turned out to be B cell NonHodgkins lymphoma along with tuberculosis.
• Biopsy was confirmed by immuno
histiochemistry with CD 20 and CD 45 positive.
• Treatment for intestinal tuberculosis differs
completely from that of small bowel
lymphoma.
TREATMENT
• Patient was started on chemotherapy and antituberculous treatment (ATT) concurrently.
• Treatment:
- Chemotherapy is the primary modality of treatment as
it spreads by hematogenous spread.
- CHOP regimen.
1.Cyclophosphamide
2.Doxarubicin(H-hydroxy daunorubicin /doxorubicin)
3.Oncovin.
4.Prednisolone.
DISCUSSION
• Intestinal tuberculosis is a specific chronic intestinal
disease caused by Mycobacterium tuberculosis.
• The clinical manifestations of small bowel lymphoma
are nonspecific, such as abdominal pain, vomiting,
weight loss and intestinal perforation.
• Small bowel is second most frequent site of
gastrointestinal tract involvement by lymphoma.
• Ileum is most common site of occurrence because it
has most lymphoid tissue
• The coexistence of Tuberculosis and small bowel
lymphoma coincidental, or one disease process might
have initiated the other.
DISCUSSION
• TB and various types of malignancies can mimic each
other and have atypical clinical and radiological
expressions.
• Further research is required to determine whether TB
infection, being similar to other chronic infections and
inflammatory conditions, may facilitate carcinogenesis.
• Although new radiological imaging studies such as
combined positron emission tomography (PET) and
computed tomography (CT) have enabled clinicians to
make a more accurate diagnosis, the ability of these
disorders to clinically mimic one another may present a
serious challenge in the establishment of the diagnosis.
CONCLUSION
• Non Hodgkin’s lymphoma may be preceded by
chronic inflammatory disease and related to
immunodeficiency.
• Tuberculosis on other hand is a chronic infectious
disease whose presentation and reactivation is
promoted by cell mediated immunodeficiency.
• The coexistence of Non Hodgkin’s lymphoma and
Tuberculosis in same organ is rare.
REFERENCES
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Epstein D, Watermeyer G, Kirsch R. Review article: the diagnosis
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Qing-Qiang Zhu, Wen-Rong Zhu, Jing-Tao Wu, Wen-Xin
Chen, Shou-An Wang, World J Gastroenterology 2014
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