Advances in Nonresponsive and Refractory Celiac Disease.

Nonresponsive celiac disease (CeD) is relatively common. It is generally attributed to persistent gluten exposure and resolves after correction of diet errors. However, other complications of CeD and disorders clinically mimicking CeD need to be excluded. Novel therapies are being evaluated to facilitate mucosal recovery, which might benefit patients with nonresponsive CeD. Refractory CeD (RCeD) is rare and is divided into 2 types. The etiology of type I RCeD is unclear, a possible switch to gluten-independent autoimmunity is suspected in some patients, and type II RCeD represents a low-grade intraepithelial lymphoma. Type I RCeD remains a diagnosis of exclusion, requiring ruling out gluten intake and other nonmalignant causes of villous atrophy. Diagnosis of type II RCeD relies on the demonstration of a clonal population of neoplastic intraepithelial lymphocytes with an atypical immunophenotype. Type I RCeD and type II RCeD generally respond to open-capsule budesonide, but the latter has a dismal prognosis due to severe malnutrition and frequent progression to enteropathy-associated T-cell lymphoma; more efficient therapy is needed.

Nomogram based on computed tomography images and clinical data for distinguishing between primary intestinal lymphoma and Crohn's disease: a retrospective multicenter study.

Background: Differential diagnosis of primary intestinal lymphoma (PIL) and Crohn's disease (CD) is a challenge in clinical diagnosis. Aims: To investigate the validity of the nomogram based on clinical and computed tomography (CT) features to identify PIL and CD. Methods: This study retrospectively analyzed laboratory parameters, demographic characteristics, clinical manifestations, and CT imaging features of PIL and CD patients from two centers. Univariate logistic analysis was performed for each variable, and laboratory parameter model, clinical model and imaging features model were developed separately. Finally, a nomogram was established. All models were evaluated using the area under the curve (AUC), accuracy, sensitivity, specificity, and decision curve analysis (DCA). Results: This study collected data from 121 patients (PIL = 69, CD = 52) from Center 1. Data from 43 patients (PIL = 24, CD = 19) were collected at Center 2 as an external validation cohort to validate the robustness of the model. Three models and a nomogram were developed to distinguish PIL from CD. Most models performed well from the external validation cohort. The nomogram showed the best performance with an AUC of 0.921 (95% CI: 0.838-1.000) and sensitivities, specificities, and accuracies of 0.945, 0.792, and 0.860, respectively. Conclusion: A nomogram combining clinical data and imaging features was constructed, which can effectively distinguish PIL from CD.

Adult intussusception in the era of HIV/AIDS: A case report.

The high incidence of HIV infection in South Africa has been associated with a proportional increase in AIDS-defining cancers, including non-Hodgkin's lymphomas (NHL). Intussusception is a rare presentation of NHL, accounting for 1% - 5% of all cases of small bowel obstruction. Contribution: To our knowledge, this is the first reported case of B-cell NHL presenting with intussusceptions and small bowel obstruction in South Africa.

Clinical and endoscopic features of primary small bowel lymphoma: a single-center experience from mainland China.

Objective: The worldwide incidence of primary small intestinal lymphoma (PSIL) is increasing. However, little is known about the clinical and endoscopic characteristics of this disease. The aim of this study was to investigate the clinical and endoscopic data of patients with PSIL, with the goal of enhancing our understanding of the disease, improving diagnostic accuracy, and facilitating more accurate prognosis estimation. Methods: Ninety-four patients diagnosed with PSIL were retrospectively studied at Qilu Hospital of Shandong University between 2012 and 2021. The clinical data, enteroscopy findings, treatment modalities, and survival times were collected and analyzed. Results: Ninety-four patients (52 males) with PSIL were included in this study. The median age of onset was 58.5 years (range: 19-80 years). Diffuse large B-cell lymphoma (n=37) was the most common pathological type. Abdominal pain (n=59) was the most frequent clinical presentation. The ileocecal region (n=32) was the most commonly affected site, and 11.7% of patients had multiple lesions. At the time of diagnosis, the majority of patients (n=68) were in stages I-II. A new endoscopic classification of PSIL was developed, including hypertrophic type, exophytic type, follicular/polypoid type, ulcerative type, and diffusion type. Surgery did not show a significant increase in overall survival; chemotherapy was the most commonly administered treatment. T-cell lymphoma, stages III-IV, "B" symptoms, and ulcerative type were associated with poor prognosis. Conclusion: This study provides a comprehensive analysis of the clinical and endoscopic features of PSIL in 94 patients. This highlights the importance of considering clinical and endoscopic characteristics for accurate diagnosis and prognosis estimation during small bowel enteroscopy. Early detection and treatment of PSIL is associated with a favorable prognosis. Our findings also suggest that certain risk factors, such as pathological type, "B" symptoms, and endoscopic type, may affect the survival of PSIL patients. These results underscore the need for careful consideration of these factors in the diagnosis and treatment of PSIL.

Prognostic value of increased intraepithelial lymphocytes and lymphocytic clonality in dogs with chronic enteropathy or small-cell lymphoma.

The clinical significance of severe infiltration of small intraepithelial lymphocytes (IEL) and the results of polymerase chain reaction for antigen receptor rearrangement (PARR) in dogs with chronic enteropathy (CE) and small-cell lymphoma (SCL) are controversial. This cohort study aimed to evaluate the prognostic significance of the IEL and PARR results in dogs with CE or SCL. Although definitive diagnostic histopathological criteria for SCL in dogs have yet to be established, dogs with the histopathological findings of severe IEL infiltration were diagnosed with SCL in this study. One hundred and nineteen dogs were recruited, with 23 dogs classified as having SCL and 96 dogs as having CE. The positive rate of PARR was 59.6 % (71/119) in the duodenum and 57.7 % (64/111) in the ileum. Subsequently, three dogs with SCL and four dogs with CE developed large-cell lymphoma (LCL). The median overall survival (OS) of dogs with SCL was 700 days (range, 6-1410 days), and that of dogs with CE was not reached. In the log-rank test, shorter OS was observed in cases with histopathological SCL (P = 0.035), clonal TCRγ rearrangement in the duodenum (P = 0.012), and clonal IgH rearrangement in the ileum (P < 0.0001). The Cox proportional hazards model adjusted for sex and age showed that histopathological SCL (hazard ratio [HR] 1.74; 95 % confidence interval [CI], 0.83-3.65), duodenal clonal TCRγ rearrangement (HR, 1.80; 95 % CI, 0.86-3.75), and ileal clonal IgH rearrangement (HR, 2.28; 95 % CI, 0.92-5.70) could shorten overall survival, although their 95 % CIs included 1.0. These results indicate that severe IEL infiltration could be a useful histopathological feature for diagnosing SCL, and clonality-positive results could be a negative prognostic factor in dogs with CE. Furthermore, the development of LCL should be carefully monitored in dogs with CE and SCL..

Primary Small Intestinal Non-Hodgkin's Lymphoma: A Case Report.

BACKGROUND: Primary intestinal lymphoma has not been previously reported in our unit, and we consider it to be a very rare cause of acute small bowel obstruction. METHODS: We present an adult male with features of recurrent small intestinal obstruction who previously underwent umbilical hernia repair for the same pain. A plain x-ray and ultrasound scan showed features of intestinal obstruction but did not suggest an aetiology of his symptoms. RESULTS: He was resuscitated and underwent an exploratory laparotomy and resection of an obstructing ileal mass with mesenteric nodes. Primary anastomosis of healthy ileum was done and the post-operative period was uneventful. The tissue was reported as low-grade B-cell non-Hodgkin's lymphoma (NHL). He was placed on CHOP with a satisfactory response. CONCLUSION: Small intestinal lymphoma is a rare cause of intestinal obstruction.

CONTEXTE: Le lymphome intestinal primaire n'a pas été rapporté précédemment dans notre unité, et nous le considérons comme une cause très rare d'obstruction aiguë de l'intestin grêle. MÉTHODES: Nous présentons un homme adulte présentant les caractéristiques d'une obstruction récurrente de l'intestin grêle et ayant déjà subi une réparation de hernie ombilicale pour la même douleur. La radiographie et l'échographie ont montré des caractéristiques d'obstruction intestinale mais n'ont pas suggéré l'étiologie de ses symptômes. RÉSULTATS: Il a été réanimé et a subi une laparotomie exploratoire et la résection d'une masse iléale obstructive avec des ganglions mésentériques. Une anastomose primaire de l'iléon sain a été réalisée et la période postopératoire s'est déroulée sans incident. Le tissu a été déclaré comme étant un lymphome non hodgkinien (LNH) à cellules B de bas grade. Il a été placé sous CHOP et avec une réponse satisfaisante. CONCLUSION: Le lymphome de l'intestin grêle est une cause rare d'obstruction intestinale. Mots clés: Lymphome intestinal primaire, Obstruction intestinale récurrente, Laparotomie.

A rare case report of high-grade primary B-cell intestinal lymphoma in young adult, with a focus on radiological role in the diagnosis and management.

In contrast to the common extra-nodal intestinal lymphoma, intestinal lymphoma of primary origin is rare. We present an interesting case of 35-year-old male patient presented with abdominal pain, then deteriorated rapidly and developed small bowel perforation. Initial diagnosis was made by computed tomography, and subsequently the diagnosis was confirmed by ultrasound-guided biopsy and histopathological assessment. This case report emphasizes on the importance of the radiological role in the diagnosis and management of such case to avoid catastrophic sequalae and complications such as intestinal obstruction, perforation, and intra-abdominal sepsis.

Co-Expression of T- and B-Cell Markers in a Canine Intestinal Lymphoma: A Case Report.

An 8-year-old female neutered Labrador retriever was presented for a second opinion consultation due to vomiting and lethargy, having failed to respond to symptomatic therapy. Blood analysis revealed hyperbilirubinemia and hypoalbuminemia, associated with hypocobalaminemia. An abdominal ultrasound identified diffused bowel thickening and hypoechoic hepatomegaly. An ultrasound-guided liver fine-needle aspiration was performed for cytology and also for cell block immunocytochemistry. Gastric and duodenal biopsies were collected by gastroduodenoscopy. Liver cytology showed numerous lymphocytes, suggesting lymphoma at the hepatic infiltration stage, and immunocytochemistry in the cell block of the hepatic aspirate indicated co-expression of CD3 and CD20 in the lymphoid cells present. The histopathology of gastric and duodenal biopsies supported the hypothesis of gastrointestinal lymphoma due to heavy lymphoid infiltration of the gastric epithelium and intestinal mucosa, including the villi. Concurrent immunohistochemistry was performed using CD3, CD20, PAX5, and CD79αcy antibodies. Immunomarking was positive for CD3 and CD20, which overlapped populations of lymphoid cells, and was negative for all other antibodies. In the clonality test, lymphocyte co-expression of CD3 and CD20 was confirmed by monoclonal rearrangement of T-cell gamma receptors. The final diagnosis was type 2 enteropathy-associated T-cell lymphoma with hepatic infiltration. Co-expression was examined in conjunction with the PARR result in the presence of T-cell monoclonal rearrangement.

An Atypical Presentation of Crohn's Disease: A Case Report.

Crohn's disease (CD) is an inflammatory bowel disease affecting any portion of the gastrointestinal tract, usually the terminal ileum and the colon, with clinical manifestations such as diarrhea, fever, and weight loss. Clinical presentation of CD may include complications such as enterovesical fistulas, abscesses, strictures, and perianal disease. CD also classically presents with "skipping lesions," unlike ulcerative colitis (UC), which presents with continuous lesions. It can manifest with a wide range of extra-intestinal symptoms such as pyoderma gangrenosum, aphthous stomatitis, episcleritis, uveitis, and arthritic disease. Such a wide range of presentations leads to diagnostic difficulties, as seen in this case. Treatment modalities include steroids, antibiotics, and surgical removal of affected parts, depending on the extent of the disease. Here, we present a case of a young male who presented with manifestations of mesenteric lymphadenitis and had an intraluminal cecal mass causing obstructive symptoms, and was subsequently diagnosed with CD.

Intestinal S100/Calgranulin Expression in Cats with Chronic Inflammatory Enteropathy and Intestinal Lymphoma.

Diagnosing chronic inflammatory enteropathies (CIE) in cats and differentiation from intestinal lymphoma (IL) using currently available diagnostics is challenging. Intestinally expressed S100/calgranulins, measured in fecal samples, appear to be useful non-invasive biomarkers for canine CIE but have not been evaluated in cats. We hypothesized S100/calgranulins to play a role in the pathogenesis of feline chronic enteropathies (FCE) and to correlate with clinical and/or histologic disease severity. This retrospective case-control study included patient data and gastrointestinal (GI) tissues from 16 cats with CIE, 8 cats with IL, and 16 controls with no clinical signs of GI disease. GI tissue biopsies were immunohistochemically stained using polyclonal α-S100A8/A9 and α-S100A12 antibodies. S100A8/A9+ and S100A12+ cells were detected in all GI segments, with few significant differences between CIE, IL, and controls and no difference between diseased groups. Segmental inflammatory lesions were moderately to strongly correlated with increased S100/calgranulin-positive cell counts. Clinical disease severity correlated with S100A12+ cell counts in cats with IL (ρ = 0.69, p = 0.042) and more severe diarrhea with colonic lamina propria S100A12+ cells with CIE (ρ = 0.78, p = 0.021) and duodenal S100A8/A9+ cells with IL (ρ = 0.71, p = 0.032). These findings suggest a role of the S100/calgranulins in the pathogenesis of the spectrum of FCE, including CIE and IL.

Primary Intestinal Lymphoma in Rabbits.

Neoplasms of the intestinal tract are uncommon in rabbits and primary lymphoma of the intestinal tract is rare. This case series is the first detailed description of primary intestinal lymphoma in rabbits. We reviewed four cases of primary intestinal lymphoma in rabbits aged 5-9.5 years old with an average age of 7.8 years. Neoplastic cells in three cases were large (8 µm diameter) while one case had intermediate cells (5 µm diameter). Neoplastic lymphocytes were of B-cell lineage and characterized by intense, multifocal, membranous immunoreactivity for CD79a and no immunoreactivity to CD3. Based on the Revised European-American Classification of Lymphoid Neoplasms/World Health Organization classification, three of the cases were consistent with diffuse large B-cell lymphoma and the case with intermediate-sized neoplastic cells was consistent with lymphoblastic lymphoma.

A Favorable Outcome of Grade 3 Follicular Lymphoma Treated With Surgery and Obinutuzumab Combined With Chemotherapy: A Case Report and Literature Review.

Follicular lymphoma is the most common type of low-grade non-Hodgkin lymphoma and the second most common type of lymphoma. Primary extranodal follicular lymphoma is rare compared with nodular follicular lymphoma involving the gastrointestinal (GI) tract. There has been uncertainty regarding follicular lymphomas due to the heterogeneous presentation and severity in which they present. However, studies showed that patients diagnosed with primary gastrointestinal follicular lymphoma do not typically differ in their presentation from those diagnosed with nodular follicular lymphoma involving the GI tract. Furthermore, recent literature identifies that patients diagnosed with grade 3 follicular lymphoma tend to have similar genetic and molecular entities to those diagnosed with diffuse large B-cell lymphoma (DLBCL). Based on these results, current studies have shown that patients with grade 3 follicular lymphoma who are treated with anthracycline-based regimens have similar outcomes to those with diffuse large B-cell lymphoma. However, additional studies are warranted to demonstrate the benefit of managing grade 3 follicular lymphoma with more aggressive anthracycline/rituximab-based regimens. Here, we present a case of a 44-year-old male diagnosed with grade 3 follicular lymphoma involving the gastrointestinal tract, who demonstrated an excellent treatment response following therapy similar to the treatment of bulky diffuse large B-cell lymphoma despite a tumor burden size below 7.5 cm.

Differential Diagnosis of Crohn's Disease and Ulcerative Primary Intestinal Lymphoma: A Scoring Model Based on a Multicenter Study.

Background: Differential diagnosis of Crohn's disease (CD) and ulcerative primary intestinal lymphoma (UPIL) is a tough problem in clinical practice. Aims: Our study identified key differences between CD and UPIL patients and aimed to further establish a scoring model for differential diagnosis. Methods: A total of 91 CD and 50 UPIL patients from 9 tertiary inflammatory bowel disease centers were included. Univariate and multivariate analyses were used to determine significant markers for differentiating CD and UPIL. A differential scoring model was established by logistic regression analysis. Results: The differential model was based on clinical symptoms, endoscopic and imaging features that were assigned different scores: intestinal bleeding (-2 points), extraintestinal manifestation (2 points), segmental lesions (1 point), cobblestone sign (2 points), homogeneous enhancement (-1 point), mild enhancement (-1 point), engorged vasa recta (1 point). A total score of ≥1 point indicates CD, otherwise UPIL was indicated. This model produced an accuracy of 83.66% and an area under the ROC curve of 0.947. The area under the ROC curve for validation using the 10-fold validation method was 0.901. Conclusion: This study provided a convenient and useful model to differentiate CD from UPIL.

Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma in the Gastrointestinal Tract in the Modern Era.

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) typically arises from sites such as the stomach, where there is no organized lymphoid tissue. Close associations between Helicobacter pylori and gastric MALT lymphoma or Campylobacter jejuni and immunoproliferative small intestinal disease (IPSID) have been established. A subset of tumors is associated with chromosomal rearrangement and/or genetic alterations. This disease often presents as localized disease, requiring diverse treatment approaches, from antibiotic therapy to radiotherapy and immunochemotherapy. Eradication therapy for H. pylori effectively cures gastric MALT lymphoma in most patients. However, treatment strategies for H. pylori-negative gastric MALT lymphoma are still challenging. In addition, the effectiveness of antibiotic therapy has been controversial in intestinal MALT lymphoma, except for IPSID. Endoscopic treatment has been noted to usually achieve complete remission in endoscopically resectable colorectal MALT lymphoma with localized disease. MALT lymphoma has been excluded from post-transplant lymphoproliferative disorders with the exception of Epstein-Barr virus (EBV)-positive marginal zone lymphoma (MZL). We also describe the expanding spectrum of EBV-negative MZL and a close association of the disease with the gastrointestinal tract.

A rare case of primary non-metastatic Non-Hodgkin's diffuse large B-cell lymphoma in the ileum in a 19-year-old male manifested as intestinal obstruction- A case report.

INTRODUCTION AND IMPORTANCE: The gastrointestinal system is the most common site for extra-nodal NHL. Adolescent population are among the rarest of compromised groups, especially males. The gastrointestinal system is more involved by secondary metastasis rather than by primary lymphomas. Cardinal B-Symptoms and obstipation constituted the presentation of our patient who was diagnosed postoperatively as a case primary non-metastatic NHL. NHL can have misleading presentations which result in the implementation of different treatment modalities. We ought to have high clinical suspicion when presented with a patient suffering from B-Symptoms and obstipation to make timely judgements which help in performing effective therapeutic interventions to limit the morbidity and mortality which result from this pathology. CASE PRESENTATION: We present the case of a 19-year-old male, who presented with obstipation and B-Symptoms. CT scan indicated loop dilation, a lobulated mass, and what radiologically seemed to be intussusception. Surgery was done and the resected specimens were DLBCL. CLINICAL DISCUSSION: We treated him by surgical excision of the affected ileal segments. Histopathology indicated a primary Non-Hodgkin's DLBCL of the ileum. Afterwards, we referred him for adjuvant chemotherapy. Treatment modalities for this malignancy are mainly surgical in addition to Chemotherapy. CONCLUSION: Intestinal extranodal NHL presents with an array of vague symptoms. As a result, this type of tumors can be clinically indistinguishable from other gastrointestinal malignancies. It is vital to keep this type of malignancy in mind as a differential diagnosis when presented with a surgical abdomen in a patient with B-Symptoms.

A Case of Multifocal Burkitt Lymphoma in an Immunocompromised Patient.

Non-Hodgkin lymphoma is made from the B-cell lineage and includes extra-nodal marginal lymphomas, follicular lymphomas, mantle cell lymphoma, diffuse large B-cell lymphoma, and Burkitt lymphoma. Burkitt lymphoma is associated with Epstein Barr Virus and Human Immunodeficiency Virus. Although it is common for other B-cell lymphomas to develop in the stomach, it is less common for Burkitt lymphoma tumors to manifest there. Additionally, primary and/or secondary involvement of the duodenum, pancreas, and intestines is very rare in Burkitt lymphoma. Herein, we present a male diagnosed with extensive Burkitt lymphoma of the bone, lymph nodes, pancreas, small intestine, duodenum, and stomach.

Immunophenotyping of intraepithelial lymphocytes in canine chronic enteropathy and intestinal T-cell lymphoma using endoscopic samples.

Human enteropathy-associated T-cell lymphoma (EATL) is considered to be derived from intraepithelial lymphocytes (IELs); however, the origin of canine intestinal T-cell lymphoma (ITCL) remains unclear. Histological, immunohistochemical, and clonality examinations were performed using endoscopically collected canine duodenum samples of mucosal lesions of chronic enteropathy (CE; 73 cases) and ITCL without transmural neoplastic mass lesions (64 cases). Histopathological examinations revealed the intraepithelial accumulation of lymphocytes (called "intraepithelial lymphocytosis") in 54/73 CE cases (74%) and the epitheliotropism of neoplastic lymphocytes in 63/64 ITCL cases (98%). Immunohistochemically, IELs in CE with intraepithelial lymphocytosis (IEL+CE) were diffusely immunopositive for CD3, with scattered immunopositivity for CD5, CD8, CD20, and granzyme B (GRB). The percentage of CD8+ in CD3+ IELs was significantly lower in IEL+CE than in CE without intraepithelial lymphocytosis (IEL-CE). Double-labeling immunohistochemistry revealed a high percentage of GRB expression in CD8- IEL among IEL+CE. Among 64 ITCL cases, CD3 was immunopositive in 64 (100%), CD5 in 22 (34%), CD8 in 8 (13%), CD20 in 12 (19%), CD30 in 13 (20%), and GRB in 49 (77%). In CD3+ cells, Ki67 immunopositivity was highest in ITCL, intermediate in IEL+CE, and lower in IEL-CE. A clonal TCR gene rearrangement was detected in 1/19 IEL-CE cases (5%), 15/54 IEL+CE (28%), and 38/58 ITCL (66%). These results indicate that the immunophenotype of canine ITCL (CD8-GRB+) is similar to that of the increased IELs in CE. The high proliferative activity and clonality of T cells in IEL+CE suggest that canine ITCL originates from these IELs, similar to human EATL.

Imaging of Bowel Lymphoma: A Pictorial Review.

Intestinal lymphoma, although rare, is the second most common extra-nodal site of lymphoma, following stomach. It is usually secondary to systemic involvement and is predominantly of non-Hodgkin's subtype. In addition to the risk factors for lymphomas occurring elsewhere, certain risk factors are specific for intestinal lymphoma. These include enteropathies such as celiac disease and inflammatory bowel disease. Imaging is the cornerstone in the management of intestinal lymphoma. Contrast-enhanced computed tomography or positron emission tomography-computed tomography are the preferred modalities for diagnosis, staging, monitoring response to treatment, and for follow-up evaluation. Bowel lymphomas can have various morphological patterns on imaging; however, certain characteristic features, if present, may prove invaluable in its diagnosis. Hence, it is imperative to be acquainted with the myriad of imaging findings in bowel lymphoma and its complications which may not only help in vivo distinction from other commoner bowel lesions but alter the management accordingly.

Monomorphic epitheliotropic intestinal T-cell lymphoma presenting as melena with long-term survival: A case report and review of literature.

BACKGROUND: Monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) is a rare primary intestinal T-cell lymphoma, previously known as enteropathy-associated T-cell lymphoma type II. MEITL is an aggressive T-cell lymphoma with a poor prognosis and high mortality rate. The known major complications of MEITL are intestinal perforation and obstruction. Here, we present a case of MEITL that was diagnosed following upper gastrointestinal bleeding from an ulcerative duodenal lesion, with recurrence-free survival for 5 years. CASE SUMMARY: A 68-year-old female was admitted to our hospital with melena and mild anemia. An urgent esophagogastroduodenoscopy (EGD) revealed bleeding from an ulcerative lesion in the transverse part of the duodenum, for which hemostatic treatment was performed. MEITL was diagnosed following repeated biopsies of the lesion, and cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy was administered. She achieved complete remission after eight full cycles of CHOP therapy. At the last follow-up examination, EGD revealed a scarred ulcer and 18Fluorodeoxyglucose (18FDG) positron emission tomography/computed tomography showed no abnormal FDG accumulation. The patient has been in complete remission for 68 mo after initial diagnosis. CONCLUSION: To rule out MEITL, it is important to carefully perform histological examination when bleeding from a duodenal ulcer is observed.