Case Presentation: A 61-year-old Caucasian male presented with melena, dizziness and anemia with hemoglobin of 6.0 gm/dL. He received appropriate hemodynamic resuscitation including six units of packed red blood cells. Urgent gastrointestinal tract evaluation was planned with an esophagogastroduodenoscopy (EGD) and colonoscopy. His EGD was unremarkable, but further studies were deferred due to precarious respiratory status intra-procedurally. Due to reported chest discomfort and non-diagnostic electrocardiographic changes, he underwent cardiac evaluation that revealed multi vessel coronary artery disease. However, prior to planned cardiac surgery, he developed recurrent melena and new decrease in hemoglobin. Repeat EGD and colonoscopy were both non-diagnostic. A computerized tomographic (CT) scan of abdomen revealed a large mesenteric mass encasing and occluding the superior mesenteric artery (SMA) and vein. Additionally, small bowel entero-enteric fistula and moderate mediastinal lymphadenopathy were noted. Aspiration of the mass revealed morphological and immuno-phenotypical features consistent with classical Hodgkin’s Lymphoma (HL). Staging evaluation determined him to be stage II-A. Since the mass was encasing the SMA, he was deemed to be a high-risk surgical candidate and was planned for medical management. He underwent six cycles of chemotherapy and follow-up imaging revealed decrease in size without any recurrence of gastrointestinal hemorrhage (GIH) at six months.
Discussion: HL is a malignancy that affects the mesenteric lymph nodes in 1-4% patients. Mesenteric HL is a rare entity found in <5% of the cases. There is one reported case of small intestinal HL presenting as partially obstructing abdominal mass with GIH. Common presentations of HL include asymptomatic lymphadenopathy (70%) and mediastinal mass on chest radiography with B-symptoms (31%). Intra-abdominal masses are more frequently noted with non-HL & metastatic disease. The diagnosis of GI HL requires the absence of mediastinal or peripheral lymphadenopathy, normal leucocyte count and differential, predominance of GI lesion with or without positive adjacent lymphadenopathy and absence of hepatic and splenic involvement. It frequently involves the ileum due to high concentration of lymphoid follicles with neoplastic transformation. A diagnosis of GI HL should prompt a thorough search for additional sites of HL due to the rarity of the disease.
Conclusions: Primary intestinal HL is rare and infrequently reported, occasionally manifesting as GIH. This case emphasizes the importance of abdominal imaging in the work up of GIH, especially if EGD and colonoscopy have been unremarkable.
To cite this abstract:Nawaz M, Vallabhajosyula S, Mansour G, Sundaragiri P, Brannan T. Hodgkin’s Lymphoma Presenting As Gastrointestinal Hemorrhage. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 635. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/hodgkins-lymphoma-presenting-as-gastrointestinal-hemorrhage/. Accessed April 9, 2020.