Challenges in the diagnosis of marginal zone lymphoma with symptoms of small intestinal disease: a case report and scoping review of the literature.

Background: Marginal zone lymphoma can be accompanied by symptoms of small intestinal disease including abdominal pain and malabsorption. However, the best diagnostic approach for suspected marginal zone lymphoma is unknown and intestinal biopsies are frequently negative. We describe the case of a patient with symptoms of small bowel involvement where marginal zone lymphoma could only be detected upon peripheral lymph node resection. To assess the clinical variability of intestinal marginal zone lymphoma as a rare clinical entity, a scoping review with systematic literature research was performed. Methods: A 57-year-old man presented with a 10-year history of postprandial abdominal pain, systemic inflammation and recent weight loss. Endoscopies and a surgical small bowel specimen revealed non-specific findings. Flow cytometry from the bone marrow was highly suspicious for marginal zone lymphoma. A 2-18F-fluorodeoxyglucose-positron emission tomography/computed tomography (2-18F-FDG-PET/CT) showed hypermetabolic lymph nodes on both sides of the diaphragm. Cervical lymph node dissection finally confirmed marginal zone lymphoma. Immunochemotherapy yielded lasting oncological remission and resolved symptoms. We searched PubMed, Embase and Ovid MEDLINE® for additional case reports limited to the last 25 years. Five primary search terms combined using "AND" were used freely and as controlled vocabulary. Additional studies were identified by reviewing the reference lists of included articles. Results: Our review revealed 52 cases of marginal zone lymphoma with small intestinal manifestation. Patients presented with abdominal pain, bowel obstruction, weight loss or gastrointestinal bleeding. Diagnosis was mainly established by surgery (73%). The most frequent endoscopic findings were mucosal erosions and ulcerations. A 2-18F-FDG-PET/CT was positive in 9/15 patients. Treatment included rituximab, chemotherapy, surgery and/or radiation resulting in clinical remission in 82% of cases. Conclusions: Diagnostic workup for suspected small intestinal marginal zone lymphoma is challenging, necessitating a multidisciplinary approach. Endoscopy, imaging including 2-18F-FDG-PET/CT and small bowel resection or dissection of hypermetabolic lymph nodes can be useful. If marginal zone lymphoma is suspected vigorous diagnostic efforts are justified since remission can be achieved in most patients. Our review highlights the variable clinical presentation of this underdiagnosed disease and adds systematic data to the literature.

Aortic compression of the esophagus: A case report and literature review.

Distal aortic compression of the lower esophagus with consecutive dilatation of the proximal esophagus was first described in the literature in 1932. Here, the authors describe the case of a 66 year-old male complaining of gastroesophageal reflux. Due to a positive family history of carcinoma of the esophagus and compression of the dorsal esophagus during an esophageal barium swallow test, further tests were performed. Endoscopy and CT exam revealed a dilated esophagus due to compression of a crossing aorta. Because of mild symptoms and the absence of dysphagia, no further treatment was necessary except for the use of a proton pump inhibitor and recommended follow-ups every one to two years.

[Early detection of pancreatic cancer - The role of endoscopic and transabdominal ultrasound]. / Frühdiagnose des Pankreaskarzinoms ­ Die Rolle von Endosonografie und Sonografie.

Pancreatic neoplasms are less common tumors and have a poor prognosis when advanced. Early diagnosis would be beneficial for survival, but screening of the whole population cannot be justified with a satisfying benefit-effort correlation. Subgroups of patients with a higher than average risk are those with germ-like mutations, familial cancers risks, and mucinous cystadenomas that would benefit from surveillance programs. Other risk groups, like patients with pancreatitis, new onset diabetes, and heavy smokers, should be considered as well. Transabdominal ultrasonography is of great advantage as a first-line imaging method because of its easy access. The accuracy for adenocarcinoma diagnosis is nearly 90% while using CEUS. Endosonography is of extraordinary importance in the diagnostic approach of pancreatic tumors because of high sensitivity and specificity while using advanced imaging techniques like CEUS, elastography, and fine needle biopsy. Screening by means of EUS is also possible in high-risk situations, and a favourable cost-benefit ratio must be shown by future data.

Conservative treatment of hepatic portal venous gas consecutive to a complicated diverticulitis: A case report and literature review.

INTRODUCTION AND PRESENTATION OF CASE: Eight days after being diagnosed with multiple small strokes a 71year old male patient is readmitted with suspicion of a petit mal seizure also complained of diarrhoea and abdominal pain. The patient was stable, not febrile and neurologically intact with a slight tenderness in the left lower quadrant. An ultrasound revealed presence of air in the hepatic portal venous system and a suspicion for sigmoid diverticulitis. A CT-scan confirmed both diagnoses. We proceeded with a conservative regimen under close observation. The clinical course and laboratory results were unremarkable. DISCUSSION: The review of the literature (PubMed database) triggered 685 items with only one clinical trial establishing a scoring system to detect adult individuals, which need operation. CONCLUSION: A pneumoportogram (hepatic portal venous gas, HPVG) is a very rare and usually associated with bowel ischemia and from poor prognosis. The last decades saw the emergence of numerous other aetiologies (also benign) with a shift of paradigm from systematic emergency laparotomies to individual patient selection.