Low grade B cell gastric mucosa associated lymphoma presenting as upper gastrointestinal bleeding from non-healing stomal ulcers

Abstract

Primary gastric lymphoma is a rare tumour. It is thought that low grade gastric mucosa associated lymphoid tissue lymphoma has not been previously reported to occur in a patient with gastrojejunostomy. This report describes such a case. The patient presented with bleeding from non-healing stomal ulcers. The ulcers healed and there was regression of the tumour after eradication of Helicobacter pylori. P rimary gastric lymphoma (PGL) is a rare tumour of the stomach and accounts for only 1%-5% of all malignancies of the stomach.1 PGL may be low grade gastric mucosa associated lymphoid tumours (commonly called MALToma) or high grade B cell tumours.2 There are three main endoscopic appearances of PGL.3 4 The lesion can be tumour-like with polypoid mass, it can be ulcerative type with erosions and ulceration, or it can be hypertrophic type with large, nodular, and giant folds.3 4 We describe a patient with MALToma at the site of gastrojejunostomy, presenting as upper gastrointestinal (UGI) bleeding from stomal ulcers. Endoscopic biopsy specimens showed gastric MALT lymphoma and eradication of Helicobacter pylori led to healing of the stomal ulcers and regression of MALT lymphoma. We believe this is the first report of its kind. CASE REPORTA 50 year old man was admitted with history of melena for the past three days. He had had a similar episode of melena three months previously that lasted five days and resolved on conservative treatment. Three units of blood were transfused. Endoscopy was not performed. He had type II diabetes mellitus that was well controlled with oral hypoglycaemic drugs. He was also receiving oral pantoprazole 40 mg per day. Elective gastrojejunostomy and truncal vagotomy were performed for peptic ulcer in 1974. Between 1974 and to date he was asymptomatic and was not taking any medication. The patient denied consuming anti-inflammatory drugs and was very particular about his medication. He was a vegetarian and a teetotaller. Clinically, he was pale. There was no icterus, clubbing, cyanosis, or lymphadenopathy. Haemoglobin was 78 g/l, total and differential leucocyte counts were within normal limits. Peripheral blood film showed hypochromia and microcytosis. Fasting and postparandial blood glucose, serum bilirubin, aminotransferases, amylase, urea, blood urea, prothrombin time, INR, and platelet count were within normal limits. UGI endoscopy was performed. The gastrojejunostomy site showed severe ulceration with necrotic areas. There was oozing of blood from the ulcers. A few nodular lesions were also seen on and around the gastrojejunostomy stoma (fig 1). Both the afferent and the efferent loops were normal. The pylorus and duodenum were also normal. Argon plasma coagulation of the bleeding lesions was performed and haemostasis achieved. Multiple biopsy specimens were obtained from the margin and the surrounding area of the gastrojejunostomy stoma, the nodular lesions, and from the antrum of the stomach. One antral biopsy specimen was used for the rapid urease test and several other pieces were s...