A rare case of small bowel intussusception

A 58-year-old man was referred to our institution with a 2-month history of worsening colicky upper abdominal pain associated with eating and relieved by vomiting, and weight loss.

Gastroscopy revealed grade B reflux esophagitis, erosive gastritis, and duodenitis. A Campylobacter-like organism (CLO) test was negative for Helicobacter pylori, and duodenal biopsies were normal. Empirical triple therapy with amoxicillin, clarithromycin, and omeprazole was administered. An abdominal ultrasound was normal. A barium follow-through showed an unusual jejunal appearance with dilatation also noted ([Fig. 1]). Subsequent CT enterography suggested proximal jejunal tethering. Double-balloon enteroscopy (DBE) revealed, 10 cm beyond the ligament of Treitz, a large sessile, ulcerated 3 – 4 cm lesion, hemicircumferentially involving the small bowel wall ([Fig. 2]). Multiple biopsies were taken and a tattoo was placed proximal to the lesion. Histopathological analysis showed a dense lymphoid infiltrate including aggregates/germinal centers with perivascular activity, highly suggestive of lymphoma. Immunohistochemistry confirmed low grade B-cell mucosa-associated lymphoid tissue (MALT lymphoma).

Fig. 1 Unusual jejunal appearance with dilatation, showed by a barium follow-through (typical coiled spring appearance: large arrow, intussusceptum; small arrow: intussuscipiens).

Fig. 2  a, b A large sessile, ulcerated 3 – 4 cm lesion, hemicircumferentially involving the small bowel wall.

At 2 weeks after a first cycle with R-CVP (rituximab, cyclophosphamide, vincristine, prednisolone), the patient presented with severe abdominal pain. A computed tomography (CT) scan revealed jejunal intussusception ([Fig. 3]), but surgical review recommended conservative management. A second DBE showed no change in the lesion ([Video 1]) after three further cycles of R-CVP. For this reason, the patient’s chemotherapy was changed to a more aggressive scheme with R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisone) for a further three cycles, and a third DBE revealed a marked improvement with significant regression of the mass ([Fig. 4], [Video 2]).

Fig. 3 Jejunal intussusception revealed by computed tomography (CT) scan: a axial view; b coronal view.

Fig. 4 Marked improvement with significant regression of the jejunal lesion at double-balloon enteroscopy (DBE).

Double-balloon enteroscopy (DBE) showed no change in the lesion after four cycles of R-CVP (rituximab, cyclophosphamide, vincristine, prednisolone).

After three cycles of R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisone), double-balloon enteroscopy (DBE) revealed a marked improvement with significant regression of the mass.

MALT lymphoma is the commonest extranodal small B-cell non-Hodgkin’s lymphoma [1]. Of extranodal lymphomas, 37 % occur in the gastrointestinal tract, with 7.5 % involving the small bowel [2]. While almost 90 % of gastric MALT lymphomas are caused by Helicobacter pylori [3], the etiology of jejunal MALT lymphoma is uncertain [4]. DBE is a useful tool for the diagnosis and follow-up of small bowel lymphoma [5].

Endoscopy_UCTN_Code_CCL_1AC_2AC

Competing interests: The first author has a Research Grant in deep enteroscopy released by Imotec/Fujinon.

• References

• 1 Wotherspoon AC. Extragastric MALT lymphoma. Gut 2002; 51: 148-149
• 2 Freeman C, Berg JW, Cutler SJ. Occurrence and prognosis of extranodal lymphomas. Cancer 1972; 29: 252-260
• 3 Zullo A, Hassan C, Cristofari F et al. Effects of Helicobacter pylori eradication on early stage gastric mucosa-associated lymphoid tissue lymphoma. Clin Gastroenterol Hepatol 2010; 8: 105-110
• 4 Isomoto H, Kamihira S et al. A case of mucosa-associated lymphoid tissue lymphoma of the ampulla of Vater: successful treatment with radiation therapy. Eur J Gastroenterol Hepatol 2003; 15: 1037-1041
• 5 Tai C-M, Tu C-H, Wu H-B et al. An unexpected cause of chronic diarrhoea. Gut 2008; 57: 902, 921