A 22-year-old male patient was admitted in the surgery ward with symptoms of bowel obstruction. He had a history of vomiting and abdominal distention since 10 days. The patient had experienced similar complaints on and off for the past year. On examination, the patient's abdomen was distended and a vague swelling was noted in the umbilical region. The baseline investigations were normal with only a rise noted in the patient's erythrocyte sedimentation rate which was 70 mm at 30 minutes and 118 mm at the end of 1hour. His Mantoux tested negative. An X-ray abdomen showed multiple fluid levels and a contrast-enhanced CT scan revealed ileal wall thickening and mesenteric nodes. The surgeon proceeded with a laparotomy and resected a segment of ileum with omental adhesions and sent for histopathological examination.\nThe cut open small intestinal segment measured 34 × 6 cm. A polyp of 1.5 cm diameter was noted 18 cm from the proximal end. Two ulcers were identified, the first measuring 2 × 2.5 cm was 14 cm from the proximal end and the second, measuring 2 × 1.5 cm was 20cm from the proximal end. Both ulcers were shallow, situated along the horizontal plane, with undermined edges and a fibrotic base. A stricture was present 9cm from the distal end with dilatation of the proximal segment. The serosa showed large lymph nodes measuring 4 × 5 cm, whose cut section was whitish and creamy in consistency. The areas adjacent to the ulcers showed diffuse thickening of the wall and on cut section revealed a whitish mass extending from the submucosa upto the serosa. Representative sections from each of the grossly abnormal areas and the resected margins were submitted for processing.\nSections from the polyp showed a polypoidal mass with a core containing smooth muscle fibers and was identified as a Peutz-Jeghers polyp. Sections from the ulcerated areas showed edematous lamina propria with a dense infiltration of eosinophils and lymphocytes with congested blood vessels in the submucosa and a dense lymphocytic infiltration in the muscularis propria [] and serosa. Sections from the lymph node showed partial loss of architecture, areas of necrosis and fibrosis with epithelioid cell aggregates but no definite granuloma was made out. Multiple sections from the thickened areas showed diffuse sheets of lymphocytes ulcerating the mucosa and infiltrating transmurally upto the serosa and periserosal fat. Rest of the mucosa showed focal erosions, increased eosinophilic and lymphocytic infiltrates in the lamina propria and increased intra-epithelial lymphocytes with focal shortening of villi. In view of the high suspicion of tuberculosis and lymphoma, further diagnostic modalities were sought after such as acid fast staining, polymerase chain reaction (PCR) and immunohistochemistry.\nZiehl–Neilson acid fast staining revealed numerous acid fast bacilli. The PCR was positive for tubercle bacilli. A lymphoma panel of immunohistochemical markers showed CD 45 and CD 20 positivity [] with weak positivity for Bcl2. The rest of the IHC markers such as cytokeratin, chromogranin, CD 3 and CD 10 were negative.\nThus, a final diagnosis of primary small intestinal B-cell lymphoma, tuberculosis and Peutz-Jeghers polyp was made.
A 21-year-old Turkish woman was admitted to our emergency service with complaints of abdominal pain and vomiting that had intensified over three days. This colicky abdominal pain was located in her right upper abdomen and was found to be non-radiating in nature. The pain became stronger after eating or drinking, and vomiting was found to relieve the pain for a while. Her upper abdomen was tender upon palpation, and guarding was significant in her right upper abdomen. Rebound tenderness or rigidity were not detected in our patient. In her right upper abdomen, an approximately 5cm-diameter mass was palpable and bowel sounds were significantly increased at this location. Mucocutaneous pigmentation was noted on her lips and oral mucosa (Figure ).\nHer vital signs were normal except for mild tachycardia (110 beats/min). Her leukocyte count was 13.1×109 cells/L, and her total and direct bilirubin counts were 4.0mg/dL and 2.9mg/dL, respectively. Her blood amylase level was slightly increased (230U/L). Except for the laboratory values noted, all other laboratory tests were deemed normal.\nOur patient had been previously diagnosed with PJS 5 years before; however, she had no history of prior hospitalizations or surgery. Since the age of sixteen, our patient had experienced chronic abdominal pain and perioral hyperpigmentation. Because of her current complaints, further investigation had been performed at another hospital. Endoscopic and computed tomography (CT) enteroclysis findings had only shown a small solitary polyp in her proximal jejunum.\nAbdominal plain radiographs revealed distinct air-fluid levels at the level of her duodenum. An abdominal ultrasound revealed a target sign of invagination at the level of the right upper abdomen. Her stomach and the proximal part of her duodenum were dilated on contrast-enhanced CT, indicating the presence of an obstruction. Her intra- and extra-hepatic biliary tracts were found to be dilated, which was a result of the compression of invaginated jejunal segments on the papilla (Figure ). The CT did not reveal any other polyps in her gastrointestinal tract. A colonoscopy had previously been performed in another clinic two months prior to the presenting symptoms, and the findings of that examination were normal.\nWe performed an esophagogastroduodenoscopy and found polyps in the fourth part of her duodenum. The invaginated jejunal fragments were also visualized. Reduction of the jejunal segments was attempted through gastroscopy, however this attempt was unsuccessful.\nTechnical difficulties with respect to the retroperitoneal position of her duodenum led us to carry out a laparotomy instead of a laparoscopy. Perioperative exposure revealed that the third and fourth parts of her duodenum were dilated. The Treitz ligament was loosened, and the invagination of the jejunal segments was gently reduced. We performed total excision of the polyps through an enterotomy at the last part of her duodenum (Figure ). We subsequently made a thorough examination of her gastrointestinal tract; no other masses were palpated in the remaining parts of visualized gastrointestinal tract.\nGross pathologic findings revealed an 8cm × 4cm × 3cm polypoid tissue mass. Histopathological examination revealed a hamartomatous polyp with adenomatous changes, without evidence of any malignancy. Immunohistochemical examination showed branching smooth muscle bands in the stroma of the polyp as typically seen in hamartomatous polyps of PJS (Figure ).\nOur patient had an uncomplicated postoperative course and was discharged home on postoperative day six. During the two-year follow-up period, our patient did not have any further episodes of intussusception.