Small bowel ischemia secondary to mesenteric lymphoma

Mesenteric involvement is the main finding in 30-50% of patients with non-Hodgkin’s lymphomas (NHL). Diffuse large B cell lymphoma (DLBCL) is the most common type of lymphoma in adults (40-50% of NHL). Mesenteric lymphomas can reach a large size without causing clinical symptoms. The most common symptoms are abdominal pain and a palpable abdominal mass. Systemic signs such as fever, night sweats and weight loss may be present in advanced stages. Mesenteric lymphoma may involve the small bowel by direct extension or mass effect. However, the majority of patients do not show signs of small bowel obstruction or bleeding or perforation. Computed tomography (CT) is the gold standard for diagnosis and the characteristic appearance is the “sandwich sign” as a result of the infiltration of the leaves of the mesentery. Differential diagnosis includes carcinoma, sarcoma, carcinoid tumour, tuberculosis, Whipple disease and inflammatory bowel disease. Although the CHOP regimen is considered the gold standard for treatment of patients with DLBCL, the addition of rituximab results in a significant improvement of the outcomes, with an increased rate of full response, decreased treatment failure and relapse rates, and improved event-free and overall survival. An 84-year-old man with a medical history of diverticulosis and Diffuse Large B-Cell Lymphoma originated from a follicular lymphoma grade 3A diagnosed in 2010 and treated with chemotherapy. He came to the Emergency Department complaining of a 7-day history of hypogastric abdominal pain and fever. The blood test showed a high CRP with no leukocytosis. A CT scan was performed that showed an ischemia of a small bowel loop secondary to compression of the vascular supply by a mesenteric tumour compatible with mesenteric lymphoma (FIG1, FIG2).

An exploratory laparoscopy was performed and converted to open surgery due to distension of the small bowel. A purulent peritonitis was observed with small bowel perforation and ischemia of 1 meter of small bowel secondary to compression by the mesenteric mass. Resection of 1 meter of small bowel with primary anastomosis was performed.

The postoperative evolution was uneventful.