Introduction: Diffuse large B-cell lymphoma (DLBCL) is the most common form of aggressive non-Hodgkin lymphomas (NHLs) in the United States. NHL accounts for 4% of US cancer diagnoses, and incidence has increased by 168% since 1975. We report a rare case of massive GI bleeding caused by gastric large B cell lymphoma.
Case Description/Methods: A 76-year-old lady, with a past medical history significant for breast cancer status post right mastectomy and chemoradiation, presented to the emergency department with 2 episodes of hematemesis and 1 episode of melena with associated dizziness. She was found to be hypotensive with a hemoglobin of 6.2 g/dl. She was admitted to the intensive care unit where she was stabilized and intubated. The patient underwent an esophagogastroduodenoscopy which showed multiple bleeding gastric nodular masses, controlled with hemostatic spray. The biopsy indicated a large B cell lymphoma with IRF4 rearrangement with no MYC/IGH fusion and no rearrangement of MYC, BCL2, or BCL6. A fluorodeoxyglucose (FDG) PET/CT confirmed an intensely FDG avid mural thickening and nodularity of the partial intrathoracic stomach consistent with gastric DLBCL. On bone marrow biopsy, no morphologic features of involvement by lymphoma were noted. The patient was referred to Oncology, with plans to start chemotherapy with the RCHOP regimen (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone).
Discussion: DLBCL is the most common lymphoma, accounting for about 25% to 30% of all the NHLs. It typically presents as a rapidly growing mass or enlarging lymph nodes in a nodal or extra-nodal site. Patients with gastrointestinal (GI) involvement usually report epigastric pain, dyspepsia, and/or weight loss for a duration ranging between a few weeks to several years. Bleeding and perforation are rare initial presentations or accompanying symptoms of NHLs. Nonetheless, massive GI bleeding can increase the morbidity and mortality risk of DLBCLs.
Lymphoma-related GI bleeding is difficult to control with conventional endoscopic hemostatic techniques, such as argon plasma coagulation, electrocautery, and mechanical hemostasis.
Hemospray can be used for initial hemostasis in high-risk cases as a temporary measure allowing sufficient time toward more definitive therapy.
