P0484 - Gastric MALT Lymphoma: An Uncommon Cause of Occult GI Bleeding and Severe Iron Deficiency Anemia

Jamil M. Shah, MD, Eric O. Then, MD, Manan A. Jhaveri, MD, Mohamed Barakat, MD, Yingxian Liu, MD, Aam A. Baqui, MD, PhD, Madhavi Reddy, MD, FACG, Denzil Etienne, MD
Brooklyn Hospital Center, Brooklyn, NY

Introduction: MALT lymphomas involve mucosa-associated lymphoid tissue (MALT), often of the stomach, but can affect almost any mucosal site. They originate from B cells in the marginal zone of the MALT, and are also called extranodal marginal zone B-cell lymphomas.

Case Description/Methods: 71 y/o man, with PMH of stage IE gastric MALT lymphoma (diagnosed in 2014) s/p completion of H. pylori treatment, PUD, HTN, h/o sinus bradycardia with PACs, PVD, COPD, cataracts, glaucoma, legally blind, dementia, depressive disorder, former smoker, and hernia repair, presented from the nursing home for exertional dyspnea, lightheadedness, and weakness for two days. He never had episodes of overt GI bleeding. Also, over the last six months, he had an unintentional 35-lb. weight loss, poor appetite, and early satiety. No NSAIDs, antiplatelet agents, or anticoagulation. No significant family history. No prior colonoscopy. Of note, surveillance EGDs in 3/2014, 6/2014, and 9/2014 were negative for H. pylori but positive for gastric MALT lymphoma. In the ED, vital signs were HR 108 and BP 94/62. Physical exam showed a pale elderly man with dry mucus membranes. Rectal exam was normal, but a fecal occult blood test was positive. Of note, earlier that month, his Hb was 13.2 g/dL. Now, his Hb was 6.0 g/dL. IV PPI bolus, PPI infusion, and IV fluids were started. He received PRBC transfusions with adequate Hb response. EGD showed a 4-cm hiatus hernia, a 4-5 cm irregularly shaped, deep, cratered, clean-based ulcer with heaped up edges in the gastric body, and a few small superficial ulcers in the duodenal bulb (Fig 1A). Biopsy results showed no H. pylori, no intestinal metaplasia, but features suggestive of the patient’s known history of MALT lymphoma (Fig 1B). Cytogenetic correlation with FISH was positive for t(11;18), a common translocation in MALT lymphomas. Colonoscopy showed diverticulosis, a few hyperplastic rectal polyps, and internal hemorrhoids. The Hb remained stable, and he was discharged. Then, with his Oncologist, he completed four cycles of Rituximab. Surveillance EGDs in 10/2018 and 3/2019 showed scar tissue suggestive of a healed ulcer in the stomach where a previous ulcer was seen, but no evidence of disease (Fig 1C).

Discussion: Gastric MALT lymphomas are associated with chronic inflammation due to H. pylori. Roughly 70% of localized non-bulky tumors have complete histologic regression after H. pylori eradication – now the mainstay of therapy. Patients still need frequent histologic surveillance for tumor recurrence


Figure: Figure 1A. Image from initial EGD. A 4-5 cm irregularly shaped, deep, cratered, clean-based ulcer with heaped up edges was found in the greater curvature of the anterior wall in the gastric body.

Figure 1B. Biopsy results showed no H. pylori, no intestinal metaplasia, but features suggestive of the patient’s known history of MALT lymphoma. There are heavy lymphoid aggregates. There is a perifollicular infiltrate of small lymphoid cells with irregular nuclei. Immunohistochemical stains revealed diffuse CD20 positive B-cells; and CD3, CD5 positive T-cells.

Figure 1C. Image from subsequent surveillance EGD. There was scar tissue suggestive of a healed ulcer in the stomach where a previous ulcer had been seen, but no evidence of disease.


Disclosures:
Jamil Shah indicated no relevant financial relationships.
Eric Then indicated no relevant financial relationships.
Manan Jhaveri indicated no relevant financial relationships.
Mohamed Barakat indicated no relevant financial relationships.
Yingxian Liu indicated no relevant financial relationships.
Aam Baqui indicated no relevant financial relationships.
Madhavi Reddy indicated no relevant financial relationships.
Denzil Etienne indicated no relevant financial relationships.


Jamil M. Shah, MD, Eric O. Then, MD, Manan A. Jhaveri, MD, Mohamed Barakat, MD, Yingxian Liu, MD, Aam A. Baqui, MD, PhD, Madhavi Reddy, MD, FACG, Denzil Etienne, MD. P0484 - Gastric MALT Lymphoma: An Uncommon Cause of Occult GI Bleeding and Severe Iron Deficiency Anemia, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.