Clinical epidemiology--how important now?

Synchronous colonic adenoma and intestinal marginal zone B-cell lymphoma associated with Crohn's disease: a case report and literature review

Background

Lymphoma and dysplasia are rare complications of long-standing Crohn’s disease. We report an exceptional case of a synchronous intestinal marginal zone B-cell lymphoma (MALT lymphoma) and colonic adenoma in a Crohn’s disease patient.

Case presentation

A 50-year-old male patient presented with right lower quadrant for the last 9 months. He also had associated weight loss and diarrhea alternating with constipation. Ileo-colonoscopy revealed a pseudopolypoid appearance of the colonic and ileal mucosa with many discontinuous ulcerations with a 3 cm sessile polypoid mass at 17 cm from the anal verge. Histological examination of the polypoid lesion revealed an adenoma with high grade dysplasia, while the biopsies of colonic mucosa showed histologic features of Crohn’s disease. Abdominal computed tomography scan (CT scan) and magnetic resonance imaging (MRI) showed circumferential wall thickening of the colon and ileum, enlarged mesenteric lymph nodes and a sessile polypoid mass of the rectosigmoid junction. The patient was scheduled for an ileocoletectomy with resection of the upper rectum and ileorectostomy.

The histological examination of the resected segment showed histologic features of Crohn’s disease, a recto-sigmoid polyp with high grade.

dysplasia and extensive small lymphocytic infiltrate in both colonic and ileal wall which is strongly stained by CD20 and BCL2. The diagnosis of MALT lymphoma with adenoma on a background of Crohn’s disease was made.

The patient successfully completed 8 cycles of Rituximab+ chlorambucil chemotherapy.

Nowadays the patient is asymptomatic without evidence of lymphoproliferative recurrence 10 months after surgery.

Conclusion

We report the first case in the literature of Malt lymphoma with colonic adenoma associated with Crohn’s disease, and discuss his unique macroscopic and histological features in a patient.

Without immunosuppressive therapy.

Positive predictive value of the International Classification of Diseases, 10th edition diagnosis codes for anemia caused by bleeding in the Danish National Registry of Patients

Objective

Valid data on anemia caused by bleeding are needed for epidemiological research and monitoring health care. The Danish National Registry of Patients (DNRP) is a nationwide medical database with information on all Danish residents’ hospital history. We aimed to assess the positive predictive value (PPV) of the diagnostic coding of anemia caused by bleeding in the DNRP.

Methods

In the DNRP, we identified all patients with International Classification of Disease, 10th edition codes for anemia caused by bleeding (acute: D50.0; chronic: D62.6) at three Danish hospitals from 2000 through 2009. For these patients we computed the PPV using hemoglobin level data, from Aarhus University laboratory database, as reference standard. Anemia was defined by a hemoglobin level less than 7.0 mmol/L for women and less than 8.0 mmol/L for men.

Results

We identified 3391 patients in the DNRP with a diagnosis of anemia caused by bleeding. The overall PPV was 95.4% (95% confidence interval [CI]: 94.6%–96.0%). The PPV was 97.6% (95% CI: 96.6%–98.3%) for men and 94.0% (95% CI: 92.9%–94.9%) for women, and the PPV increased with age at diagnosis. The PPV varied according to type of discharging departments, from 89.2% (95% CI: 83.4%–93.4%) in gynecology to 96.8% (95% CI: 94.9%–98.2%) in surgery, and was lower for outpatients compared with inpatients.

Conclusion

We found a high PPV of the coding for anemia caused by bleeding in the DNRP. The registry is a valid source of data on anemia caused by bleeding for various purposes including research and monitoring health care.

Mesentery lymphoma in a patient with Crohn's disease: An extremely rare entity

INTRODUCTION

Lymphoma is a rare complication of long-standing Crohn's disease. We report a rare case of a diffuse, B-cell non-Hodgkin's lymphoma of the mesentery in a patient receiving treatment for Crohn's disease.

PRESENTATION OF CASE

A 52 year-old patient presented with abdominal pain, anorexia and postprandial fullness. Abdominal examination revealed a firm mass, extending from the epigastrium to the right iliac fossa. CT scan showed a large intra-abdominal mass with air-fluid levels within, and soft tissue density along its walls, surrounded by distended bowel loops. The patient was scheduled for surgery due to clinical assumption of an intra-abdominal abscess. At laparotomy an ill-defined, lobulated mass with cystic areas was noted rising from the mesentery. Frozen section biopsy of the cystic mass revealed a non-Hodgkin follicle center B-cell lymphoma of the mesentery.

DISCUSSION

To the best of our knowledge, this is an extremely rare case of lymphoma development in the mesentery, in a patient receiving treatment for Crohn's disease. Although the development of abdominal lymphomas can be justified as a possible consequence of the chronic immune-modulating therapy, their location can lead to diagnostic pitfalls.

CONCLUSION

Although mesentery has scarcely been presented as a potential site of occurrence of abdominal lymphomas in the process of treatment of inflammatory bowel diseases, this rare entity should be considered in the differential diagnosis of intra-abdominal lymphomas in patients with inflammatory bowel disease. In cases where imaging techniques do not provide definitive answers, surgical intervention can safely pose the accurate diagnosis.