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 24-year-old Caucasian man presented with an acute onset of melaena to the Emergency Department of our hospital. He had no abdominal pain, or history of change in bowel habit or any significant loss of weight or appetite. He was previously healthy and took no regular medications. He had no family history of gastrointestinal disorders. Our patient was also a non-smoker and had no history of illicit drug use.\nUpon admission, he was hypotensive and tachycardic. However, abdominal examination was completely unremarkable. Rectal examination revealed black tarry stool. Multiple dark pigmented patches were noted on the buccal mucosa of our patient. Laboratory tests revealed microcytic, hypochromic anaemia with a haemoglobin of 7.6 gm%. Blood urea was elevated at 12 mmol/litre. Initial assessment showed no other abnormalities.\nHe was resuscitated and required transfusion of six units of blood. Urgent upper gastrointestinal endoscopy revealed polyps in the stomach and duodenum, but no active bleeding sites were found. The presence of buccal pigmentation and multiple polyps on endoscopy suggested a diagnosis of PJS. A computed tomography (CT) scan of the abdomen of our patient was therefore performed. This confirmed multiple small bowel intussusceptions. (Figure )\nUrgent laparotomy was undertaken on our patient and the intussusceptions were reduced. Through enterotomies, eight polyps were removed from the affected segment of the gut. The affected segment of gut was found to be viable. He had a fairly uneventful recovery with no further bleeding. Pathological examination of the polyps confirmed hamartomas with smooth muscle arborisation, compatible with Peutz Jeghers polyps. No features of pseudo-invasion were noticed in any of the polyps. (Figure )