Introduction: Lymphoma originating from the gastrointestinal tract is rare and accounts for only 1%-4% of malignancies arising in the stomach, small intestine or colon. Patients often present with nonspecific symptoms and despite the application of advanced imaging techniques, diagnosis can be challenging. We present a case series of 2 patients with ambiguous gastrointestinal symptoms and a subsequent diagnosis of primary intestinal lymphoma. Case Description/Methods: Case 1: A 43-year-old man with a medical history of sarcoidosis presented with 3 months of periumbilical pain and a 30-pound, unintentional weight loss. Physical exam, laboratory investigation, esophagogastroduodenoscopy (EGD), colonoscopy and video capsule endoscopy (VCE) were unremarkable. CT abdomen and pelvis revealed a partial small bowel obstruction (Figure 1A). A subsequent small bowel enteroscopy (SBE) demonstrated a nonspecific inflammation of the ileum. Additionally, a CT enterography disclosed the presence of a stricture in the mid-ileum. Given the unclear etiology of the pathology 3 months following presentation, small bowel resection was performed and pathology revealed a diffuse large B-cell lymphoma. Case 2: A 55-year-old woman with a medical history of Lynch syndrome presented with one month of abdominal pain, vomiting and a 5-pound, unintentional weight loss. The physical exam and laboratory investigation were normal. Magnetic resonance enterography showed a 6 cm proximal ileal segment with irregular concentric wall thickening. SBE revealed nodular ileal mucosa with ulceration in the mid-ileum (Figure 1B). Biopsies demonstrated low-grade follicular lymphoma and this was demonstrated 4 months after presentation. Discussion: Presenting symptoms of primary intestinal lymphoma are vague and commonly include abdominal pain, hematochezia, melena or changes in bowel habits. Radiological findings are often nonspecific and may present a challenge in distinguishing lymphoma from other lesions, benign or malignant. While VCE and small bowel enteroscopy with biopsies have improved the identification of small intestinal pathologies, a nonspecific clinical presentation can result in delayed intervention. Thus, diagnosing primary intestinal lymphoma remains a challenge and further research is needed to provide insight on the best practice for its diagnosis and treatment.Figure 1.: A: Computed tomography enterography showing mild hyperenhancement in the narrowed region (red arrow). B: Small bowel enteroscopy demonstrating ulcerated nodular mucosa in the ileum.
A number of skill sets will be described, which are needed to learn endoscopic ultrasound (EUS). To master these skill sets, one needs a variety of learning tools. There are two main pathways to learning EUS: either as part of a mentored fellowship program (either part of traditional 3-year fellowship training or fourth year advanced endoscopy fellowship) or self-learning for practicing gastroenterologists. The new EUS Training program established by the American Society for Gstrointestinal Endoscopy is an additional new and much needed training option for those outside of fellowship looking for an avenue to learn EUS. Regardless of the training path followed, once an endoscopist is performing EUS, the expectation is that they are performing high-quality procedures. Good initial training, followed by ongoing practice and continued medical education in EUS, should result in increasing availability of high-quality EUS procedures.
