Non-Hodgkin lymphoma presenting with obstructive jaundice

Burkitt Lymphoma Presenting as Obstructive Jaundice: A Case Report and Literature Review

Burkitt lymphoma (BL) is an aggressive, high-grade B-cell lymphoma common in children and young adults. Despite being frequently discovered in extranodal sites, BL rarely occurs in the pancreas. We present a case of a patient with BL presenting as obstructive jaundice.

Treatment of obstructive jaundice induced by non-hodgkin lymphoma with EUS-guided transgastric anterograde common bile duct stenting: Technical case report and literature review

Background

Non-Hodgkin lymphoma (NHL) is a rare cause of biliary obstruction. The optimum treatment for these patients is unclear. Lymphoma-associated obstructive jaundice is generally managed with open surgery, Endoscopic retrograde cholangiopancreatography (ERCP), or Percutaneous transhepatic biliary drainage. Here, we present the first description of EUS-guided anterograde common bile duct stenting via the stomach for obstructive jaundice associated with NHL.

Patient and methods

A 58-year-old male patient who had been undergoing chemotherapy for NHL was admitted to our institution for severe obstructive jaundice. The patient's hepatic function indicators were: alanine aminotransferase 211 U/L, aspartate aminotransferase 301 U/L, total bilirubin 485.6 μmol/L, and direct bilirubin 340.2 μmol/L. Abdominal magnetic resonance imaging showed massive lymphomatous lesions filling the peritoneal cavity. Magnetic resonance cholangiopancreatography revealed an external compressive stricture in the superior middle common bile duct and dilation of the intrahepatic and extrahepatic ducts. ERCP was performed unsuccessfully, due to the stricture at the descending junction of the duodenal bulb caused by lymphoma infiltration. So, EUS-guided anterograde common bile duct stenting via the stomach was performed.

Results

The patient's bilirubin level decreased significantly in the postoperative period, and no adverse reaction was observed. Computed tomography showed marked shrinking of the abdominal mass after targeted therapy.

Conclusions

Our report suggests that early relief of biliary obstruction may be more beneficial to subsequent chemotherapy when symptoms of lymphoma-associated jaundice are persistently aggravating. Endoscopic ultrasound-guided biliary drainage is a safe, effective and timely alternative approach to treat biliary obstruction when ERCP fails, especially in cases of malignancy caused by extrahepatic bile duct space-occupying lesions.

Complications of lymphoma in the abdomen and pelvis: clinical and imaging review

Involvement of the abdomen and pelvis is common in lymphoma. Nodal and extranodal abdominal and pelvic lymphoma may present with various complications. Complications are most common in high-grade lymphomas, especially diffuse large B-cell lymphoma. Complications may occur as the initial manifestation of lymphoma, during treatment course, or late following complete disease remission. Most complications are associated with worse prognosis and increased mortality. Imaging is essential in evaluation of disease extent and diagnosis of complications. Therefore, radiologists should be familiar with the clinical context and imaging features of abdominal and pelvic lymphoma complications. We provide a comprehensive, organ system-based approach, and clinical and imaging review of complications of abdominal and pelvic lymphoma along with radiologic images of illustrated cases of the most commonly encountered complications.

Primary biliary non-Hodgkin's lymphoma: A case report

RATIONALE

Primary biliary non-Hodgkin's lymphoma (PBNHL) is a rare disease with only 41 cases reported since 1982. The incidence of PBNHL in patients with malignant cholangiocarcinoma was 0.6%, and PBNHL accounted for 0.4% of extranodal non-Hodgkin's lymphoma, and only 0.016% of all non-Hodgkin's lymphoma cases.

PATIENT CONCERNS

We present a rare case of PBNHL in a 59-year-old female who had jaundice for 3 days with weight loss and Epstein-Barr virus infection. Initial computed tomography and magnetic resonance imaging showed diffuse thickening wall of bile ducts with corresponding lumen stenosis, blurred fat space around the portal vein, lymphadenopathy, and a normal spleen. These manifestations and images were similar to hilar cholangiocarcinoma. So, the diagnosis of hilar cholangiocarcinoma was initially considered.

DIAGNOSES

Postoperative pathology confirmed the final diagnosis was PBNHL.

INTERVENTIONS

The patient and her family requested to clarify the histologic diagnosis by laparotomy biopsy. Because the biopsy result could not be defined during operation, then right hemihepatectomy and choledochojejunostomy were performed. She did not receive any antitumor treatment.

OUTCOMES

One month after the patient's first examination, both computed tomography and magnetic resonance images showed diminished stenosis of common bile duct and left hepatic duct, but a new mass in segment IV of liver was observed. Unfortunately, the patient died due to disease progression.

LESSONS

This case reminds us that although PBNHL is rare, making accurate diagnosis difficult preoperatively, PBNHL should be considered when encountering a case with Epstein-Barr virus infection and those typical imaging findings.

Burkitt lymphoma associated with human immunodeficiency virus infection and pulmonary tuberculosis: A case report

INTRODUCTION

The association of human immunodeficiency virus (HIV) infection with Burkitt lymphoma is related to the presence of Epstein Barr virus infection and the impact of the HIV antigen on the expansion of B-polyclonal cells. In Southeast Europe, the association is rare, and recognizing this is important in the therapeutic decision to increase patient survival rate. The association of HIV with Burkitt lymphoma and tuberculosis is even more rarely described in the literature.

PATIENT CONCERNS

We present the case of a 40-year-old patient who presented with a 3-week history of fever (max. 38.7 °C), painful axillary swelling on the right side, lumbar pain, gait disorders, headache, and night sweats. Clinical manifestations included marked weight loss (about 30 kg in the last 2 months before his admission).

DIAGNOSIS

A LyCD4 count of 38/μL and a HIV1 viral load of 384,000/mm3, classified the patient into a C3 stage. A biopsy of the right axillary lymph node was performed for suspected ganglionic tuberculosis due to immunodeficiency. Histopathological examination confirmed the diagnosis of Burkitt lymphoma. Cultures on Löwenstein-Jensen medium from sputum harvested at first admission were positive for Mycobacterium tuberculosis.

INTERVENTIONS

Highly active antiretroviral therapy, chemotherapeutic agents for Burkitt lymphoma, anti-tuberculous drug therapy, neurosurgical intervention of spinal cord decompression, and antibiotic therapy of the associated bacterial infection.

OUTCOME

Burkitt lymphoma disseminated rapidly, with central nervous system, spinal cord, osteomuscular, adrenal, and spleen involvement. The evolution under treatment was unfavorable, with patient death occurring 6 months after diagnosis.

CONCLUSIONS

The association of HIV infection with Burkitt lymphoma and tuberculosis is rare in the highly active antiretroviral therapy (HAART) era, posing prompt and multidisciplinary therapeutic management issues. Similar cases of HIV-TB and Burkitt lymphoma association have been described, but none of the other cases showed the involvement of the central nervous system or of the bilateral adrenal glands.

A Case of Secondary Sclerosing Cholangitis in the setting of Non-Hodgkin's Lymphoma

Sclerosing cholangitis represents a spectrum of cholestatic liver disease characterized by inflammation, fibrosis, and stricture of the bile ducts. A 67-year-old Caucasian female with a history of breast cancer in remission, presented with jaundice and an exophytic mass at the base of the tongue. Laboratory data revealed cholestasis with alkaline phosphatase 953 U/L, total bilirubin 7.7 mg/dL, direct bilirubin 6.4 mg/dL, and gamma-glutamyltransferase 3369 U/L. Computed tomography (CT) scan showed widespread lymphadenopathy in the chest, abdomen, and pelvis concerning for lymphoma, acute pancreatitis and biliary dilation with hyperenhancement of the common bile duct wall. Diffuse intrahepatic biliary ductal dilatation and narrowing with multifocal stenosis of the proximal and distal aspects of the common bile duct was seen on magnetic resonance cholangiopancreatography (MRCP). Findings were consistent with sclerosing cholangitis. Pathology of the oral lesion revealed activin receptor-like kinase 1 (ALK1) positive anaplastic large cell lymphoma. Chemotherapy was initiated with cyclophosphamide, doxorubicin, adriamycin, vincristine, etoposide, and prednisone (CHOEP-14) regimen, which resulted in significant clinical improvement along with a remarkable decrease in the liver function tests. Non-Hodgkin's lymphoma (NHL) has only rarely been reported in the literature as a cause of secondary sclerosing cholangitis, i.e., only 0.2% to 2.0% of patients with NHL present with biliary tract obstruction. It is essential for gastroenterologists, oncologists, and radiologists to recognize sclerosing cholangitis occurring secondary to a systemic disease because early initiation of treatment can improve clinical outcome, as manifested by our case.

An unusual case of obstructive jaundice: ampullary Burkitt lymphoma

Primary lymphomas of the digestive tract are uncommon heterogenous group of neoplasms that primarily affects stomach. Lymphomatous involvement of small intestine is amongst the rare lymphomas; ampullary involvement is even rarer. It is important to recognize this entity early as it mimics periampullary neoplasms and its management is different. We present the case of a 14-year-old male who presented with rapidly progressive obstructive jaundice and weight loss and ultimately was diagnosed to have ampullary Burkitt's lymphoma. Early diagnosis of this aggressive tumor and prompt induction of chemotherapy dramatically improved the patient's condition. It is crucial to consider Burkitt's lymphoma as a differential diagnosis of obstructive jaundice as both the treatment and prognosis are markedly different.

Disseminated Burkitt's Lymphoma with a Pancreatic Mass in a HIV Positive Woman Diagnosed by Axillary Lymph Node Biopsy

Burkitt's Lymphoma (BL) is a highly aggressive B cell lymphoma of non-Hodgkin's type usually presenting in extranodal sites for endemic and sporadic types of the disease. Like other non-Hodgkin's Lymphomas (NHL), HIV positive associated BL is associated with peripheral lymphadenopathy. We present a case of 22-year-old newly diagnosed HIV positive female patient who presented with generalized peripheral lymphadenopathy and obstructive jaundice. Initial work up was suggestive of acute pancreatitis with further evaluation revealing a pancreatic head mass. BL was confirmed both by axillary lymph node biopsy and immunohistochemistry, highlighting the importance of high index of suspicion and prompt histopathological diagnosis to enable treatment of this fatal disease that is potentially curable.

Primary Hepatic Non-Hodgkin's Lymphoma: An Enigma Beyond the Liver, a Case Report

We have discussed a unique presentation of primary diffuse large cell B-cell non-Hodgkin (DLBC NHL) hepatic lymphoma involving the porta hepatis and biliary confluence causing obstructive jaundice with contiguous soft tissue involvement of the right lobe of liver extending up to the right renal cortex. This appears to be the only case in literature where primary hepatic lymphoma has shown contiguous localized intra- and extrahepatic tumor infiltration. A 67-year-old gentleman presented with history of significant loss of appetite and weight in 2 months with associated progressive painless cholestatic jaundice. Physical evaluation revealed normal vitals with pallor, deep icterus, scratch marks over the abdomen, generalized muscle wasting, grade II clubbing and a palpable non-tender liver with a globular, firm mass beneath the liver. He had a total serum bilirubin of 15.9 mg/dL and direct bilirubin of 9.24 mg/dL. His liver enzymes were moderately elevated with raised serum creatinine and dyselectrolytemia. Serology for enterohepatic viruses was negative. Contrast-enhanced magnetic resonance imaging (CEMRI) showed poorly enhancing multiple soft tissue masses in both lobes of liver with the largest mass involving, biliary confluence and porta hepatis causing right bile duct and portal vein encasement. The mass occupied the posterior right lobe and extended to the inferior surface of liver with contiguous invasion of the right renal upper pole cortex. The mass was associated with a retracted liver capsule in the involved segments and delayed enhancement, mimicking a cholangiocarcinoma. Tissue biopsy revealed hepatic DLBC type NHL and patient was subsequently treated with a CHOP-R (cyclophosphamide-doxorubicin-vincristine-prednisolone/rituximab) regimen, on which he has shown non-progressive disease at 1-year follow-up. DLBC NHL of the liver is a very rare tumor with propensity for isolated involvement of the liver and minimal extrahepatic spread. This case shows many interesting features such as obstructive jaundice for 2 months, porta hepatis involvement and tumor infiltration up to the right renal parenchyma. We have illustrated various imaging findings which should be considered when evaluating such a lesion to help differentiate it from cholangiocarcinoma. The literature is extensively reviewed. The case demonstrates relevant diagnostic parameters for physicians, radiologists and oncologists who are likely to encounter patients with tumor-induced obstructive jaundice in their daily practice.

Obstructive jaundice as an initial manifestation of non-hodgkin lymphoma: treatment dilemma and high mortality

Introduction. Non Hodgkin lymphoma (NHL) presenting with obstructive jaundice is a rare occurrence. Because of rarity of combination, it is seldom considered in differential diagnosis of patients presenting with obstructive jaundice. It is considered treatable due to the chemosensitive nature of the disease and the recent advances in chemotherapy. Case Series. We present a case series of 2 patients with NHL presenting with obstructive jaundice as an initial manifestation. Both patients presented with obstructive jaundice and were diagnosed by CT guided liver biopsy. One patient died of sepsis and multiorgan failure before initiating chemotherapy and the second patient did not choose to undergo chemotherapy. Conclusion. Biliary obstruction is a sign of poor prognosis. The diagnosis of NHL needs to be considered in patients presenting with biliary obstruction. It can be associated with high mortality and poses treatment dilemma.

Non-Hodgkin's lymphoma: a cause of paraneoplastic cholestasis

We describe a 79-year-old gentleman with a longstanding history of chronic lymphocytic leukaemia who presented with subacute onset of cholestatic jaundice. Comprehensive review of the patient's data and medications failed to reveal any obvious causes. Exhaustive testing including abdominal CT and magnetic resonance cholangiopancreatography failed to reveal any obstruction. A liver biopsy demonstrated scattered non-caseating granulomas. The patient was diagnosed with granulomatous hepatitis and treated with oral steroids and eventually improved. It was thought to be due to paraneoplastic cholestasis as an extrahepatic manifestation of non-Hodgkin's lymphoma.

An unusual cause of acute obstructive jaundice in an HIV-infected patient

We describe the case of an HIV-1-infected patient presenting with acute obstructive jaundice as the initial manifestation of primary small bowel Burkitt's lymphoma. The biliary obstruction resolved rapidly following chemotherapy without the need for surgical intervention. The prognosis is favourable with appropriate timely treatment.

Outcomes in lymphoma patients with obstructive jaundice: a cancer center experience

BACKGROUND

Little information is available to guide clinicians on the optimal approach to managing obstructive jaundice in lymphoma patients.

AIMS

The aim of this study was to review our experience in treating lymphoma patients with obstructive jaundice in order to develop guidelines as to the best interventional approach.

METHODS

We reviewed the medical records of all lymphoma patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous biliary drainage (PBD) for obstructive jaundice between June 2002 and October 2008.

RESULTS

We identified 35 lymphoma patients who underwent ERCP and/or PBD for obstructive jaundice. The mean age was 57.6 years. Most patients (66%) had diffuse large B-cell lymphoma. Stents were placed by ERCP in 25 patients and PBD in nine. Serum bilirubin levels normalized following ERCP or PBD in 29 of 33 (85%) patients with stricture. Stricture resolution occurred in 12 cases. Patients who had obstructive jaundice at the time of their lymphoma diagnosis had significantly longer mean overall survival following intervention than patients in whom obstructive jaundice developed later in the course of their disease (21.3 months vs. 4.5 months, P = 0.0001).

CONCLUSIONS

ERCP and/or PBD effectively normalized serum bilirubin levels. Plastic stents should be used in patients who have obstructive jaundice at the time of lymphoma diagnosis because these strictures tend to resolve before stent exchanges are necessary. For patients in whom obstructive jaundice develops later in the course of their disease, the limited prognosis often makes a single intervention with insertion of a plastic stent sufficient to provide adequate biliary decompression.

Primary hematolymphoid malignancies involving the extrahepatic bile duct or gallbladder

Primary hematolymphoid malignancies of the extrahepatic biliary tract are rare tumors. We report five cases of primary hematolymphoid malignancies involving the extrahepatic biliary tract. One is a granulocytic sarcoma of the extrahepatic bile duct, another is an extramedullary plasmacytoma of the gallbladder, and the others are two non-Hodgkin lymphomas of the extrahepatic bile duct and one of the gallbladder. The clinical presentations, radiographic studies, and gross findings at surgery have not been a significant help in differential diagnosis. Although a preoperative diagnosis of primary hematolymphoid malignancy is very difficult to reach because of the rarity of this disease, it should be considered, because, if an accurate diagnosis is made before surgical intervention, chemotherapy is the most appropriate treatment. In limited cases mimicking cholangiocarcinoma and gallbladder cancer, surgical resection followed by chemotherapy has a valid role as reasonable treatment for patients.

Jaundice as a presenting manifestation of pediatric non-Hodgkin lymphoma: etiology, management, and outcome

OBJECTIVES

There are few data available on the management and outcome of pediatric patients with non-Hodgkin lymphoma (NHL) presenting with jaundice. Controversies exist on biliary drainage and chemotherapy dose modifications to be carried out in such patients. The aim of this study was to analyze the causes of jaundice in, the various modalities of treatment administered to, and outcome of patients aged 18 years or less, with de novo NHL and jaundice treated at our center.

PATIENTS AND METHODS

A retrospective analysis show 9 such cases (11.2% of all NHL cases), all of whom were treated by a uniform protocol. Chemotherapy dose modifications were based on serum bilirubin and clinical status of the patients.

RESULTS

Obstructive jaundice was the most common cause (7 of 9). Seven patients achieved normal serum bilirubin with chemotherapy alone. Only one had a biliary drainage procedure. Four patients were alive and disease-free at last follow-up.

CONCLUSIONS

Although biliary obstruction is the commonest most cause of jaundice in pediatric and adolescent NHL, biliary drainage may be unnecessary and chemotherapy alone may suffice as initial treatment for these patients.

Malignant masquerade: dilemmas in diagnosing biliary obstruction

The hepatobiliary surgeon must be as familiar with the nonmalignant processes that can affect the extrahepatic biliary tree as they are with the malignant causes. Subtleties in the patient's history, presentation, and imaging studies may prevent unnecessary extensive hepatobiliary resection. The focus of this article deals with the etiology of nonmalignant obstruction at the biliary bifurcation and hilum and the mid-bile duct. It does not focus on either choledocholithiasis or pancreatitis, the two most common causes of distal bile duct obstruction. Obstruction from pancreatic cancer is also not the focus of this discussion.

Primary non-Hodgkin's lymphoma of the main hepatic duct junction

A rare case of primary non-Hodgkin's lymphoma of the main hepatic duct junction is reported. A 71-year-old man was admitted for treatment of obstructive jaundice. Radiological examination revealed stenosis of the main hepatic duct junction. Biliary drainage was not necessary because total bilirubin decreased spontaneously. A left hepatic and caudate lobectomy, combined with resection of bile ducts and lymph node dissection, was performed with the preoperative diagnosis of cholangiocarcinoma of the main hepatic duct junction. Macroscopic examination of the resected specimen revealed tumorous growth in the main hepatic duct junction. Histological and immunochemistry findings disclosed a mucosa-associated lymphoid tissue (MALT) lymphoma. The patient received three courses of combination chemotherapy [cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP)], and there was no evidence of recurrence 45 months after the surgery. Although primary non-Hodgkin's lymphoma of the main hepatic duct junction is extremely rare and difficult to diagnose preoperatively, aggressive surgery followed by chemotherapy, as here, is a possible curative option.

Non-Hodgkin lymphoma as a cause of obstructive jaundice with simultaneous extrahepatic portal vein obstruction: A case report

Non-Hodgkin lymphoma is a rare cause of biliary obstruction. To the best of our knowledge, non-Hodgkin lymphoma in the peripancreatic region causing obstructive jaundice with simultaneous portal vein (PV) invasion has not yet been reported. We present a 50-year-old patient with obstructive jaundice whose extrahepatic portal vein was obstructed by the invasion of a peripancreatic non-Hodgkin lymphoma. The patient denied any other symptoms such as recurrent fever, night sweat and loss of body weight. Computed tomography (CT) revealed a 10 cm mass in the retroperitoneal space behind the head of the pancreas causing obstruction of the distal bile duct and the PV. A pylorus-preserving pancreaticoduodenectomy combined with a PV resection was performed. The PV was reconstructed using an autologous right internal jugular vein graft. The resected specimen showed endoluminal invasion of both the bile duct and the PV. Histological examination showed the mass consisting of diffuse sheets of large malignant lymphoid cells. These cells were positive for CD20 and CD79a, partially positive for CD10, and negative for CD3, CD4, CD5, CD8 and CD30. The pathologic diagnosis was diffuse large B-cell type non-Hodgkin lymphoma and the patient was transferred to the Department of Hematology and Oncology for chemotherapy. He received four cycles of combined chemotherapy including cyclophosphamide, doxorubicin, vincristine and prednisone plus rituximab, and three cycles of intrathecal chemoprophylaxis including methotrexate, cytosine arabinoside and prednisone. The patient is alive with no evidence of the disease for 7 mo after operation and will receive additional courses of chemotherapy.

Unusual causes of extrahepatic biliary obstruction in children: a case series with review of literature

This paper highlights the etiology, diagnosis, management and outcome in nine unusual cases of extrahepatic biliary obstruction in children. Extrahepatic biliary atresia and choledochal cyst constituted 127 out of 136 (93%) cases of all pediatric surgical biliary disorders managed between March 2000 and February 2007 at the reporting centre. However, nine children (aged 1.5-15 years) presented with uncommon causes like (1) idiopathic benign non-traumatic inflammatory stricture (n = 3), (2) idiopathic fibrosing chronic pancreatitis (n = 2), (3) post-cholecystectomy type 4 benign biliary stricture (n = 1), (4) post-acute pancreatitis pseudo-cyst of pancreas (n = 1), (5) non-Hodgkin's lymphoma (NHL) with extramural common bile duct compression and gall bladder perforation (n = 1), and (6) Langerhan cell histiocytosis (LCH, n = 1). The clinical features and the diagnostic work up of each group are discussed. A preoperative endoscopic/percutaneous biliary drainage was required in four children because of cholangitis at presentation. A biliary-enteric anastomosis was performed for all seven children in groups (1)-(4). The patients with NHL and LCH were referred for chemotherapy after establishing tissue diagnosis at laparotomy. With a follow-up period of 3 months to 7 years, seven children (with the exception of patients with NHL and LCH) are currently anicteric. This paper draws attention to some infrequently discussed causes of extrahepatic biliary obstruction in children. The management entails a carefully planned combination of endoscopic interventions, interventional radiology and surgery. The outcome in benign cases is usually satisfactory.

Biliary tract obstruction secondary to malignant lymphoma: experience at a referral center

Lymphoma is a rare cause of biliary obstruction and, on cholangiography, may mimic other causes of obstructive jaundice. The optimum treatment for these patients is unclear. The aim of this study is to evaluate the incidence, clinical and imaging findings, management, and outcome of biliary obstruction caused by lymphoma. Our database was searched retrospectively for patients with biliary obstruction due to lymphoma between 1999 and 2005. Biliary obstruction secondary to lymphoma was found in 7 (0.6%) of 1123 patients with malignant biliary obstruction. One patient had benign biliary obstruction related to lymphoma. Of the eight patients (five male, three female; mean age, 34.50 +/- 17.93 years), four had Hodgkin's disease and four had non-Hodgkin's lymphoma. Biliary obstruction occurred as part of the initial or early presentation of lymphoma in two patients. The most common cause of obstruction was compression of the biliary tract by enlarged lymph nodes (six patients). Cholangiographic appearances were diverse: narrowing of the common bile duct (six patients), splayed and narrowed common bile duct (one patient), and multiple strictures and dilatations of the intrahepatic bile ducts (one patient). Biliary drainage was performed in all patients including endoscopic stent placement in six patients, nasobiliary drainage in one, and choledochoduodenostomy in one. Hyperbilirubinemia resolved in all but one of the patients with a stent; however, none could be maintained in a stent-free condition. Five patients died within 1 year after onset of jaundice. One of the surviving patients developed a late benign stricture at the site of the earlier lymphoma. We conclude that lymphoma should be considered in the differential diagnosis of obstructive jaundice, particularly in younger patients. We suggest that biliary drainage by the endoscopic or percutaneous route is necessary for the treatment of these patients. Late benign strictures may develop. Biliary obstruction is a sign of poor prognosis in lymphoma.

Nonendemic Burkitt lymphoma presenting with an atypical clinical picture

Primary appendiceal Burkitt lymphomas are rare occurring in 0.015% of all gastrointestinal lymphomas. Presentation of such lymphomas with peritonitis and obstructive jaundice owing to its subhepatic location is even more unusual. Burkitt lymphoma is very rare in children below 5 years old. We will present a 3-year-old boy with primary appendiceal lymphoma whose first symptom was obstructive jaundice caused by a ruptured retrocecal subhepatic appendix which in essence is a combination of all 3 mentioned occurrences complicated with acute abdomen.

Burkitt's lymphoma: an unusual cause of obstructive jaundice

Biliary obstruction secondary to malignancy is a common clinical problem. Rarely, biliary obstruction is due to non-Hodgkin's lymphoma. Obstructive jaundice in these patients usually presents late in the course of the disease. Burkitt's lymphoma is a subtype of non-Hodgkin's lymphoma. Unlike other forms of non-Hodgkin's lymphoma, Burkitt's lymphoma presents as an extranodal disease. We present the case of a patient suffering from non-endemic Burkitt's lymphoma whose initial presenting symptom was obstructive jaundice.

Multidisciplinary management of surgical disorders of the pancreas in childhood

OBJECTIVES

To describe the frequency and range of pancreatic disorders in children requiring surgical intervention and to highlight the importance of multidisciplinary management.

METHODS

An audit of all children under 17 years of age referred with surgical disorders of the pancreas or pancreatitis to a regional pediatric gastroenterology unit in the United Kingdom during a 10-year period. A retrospective chart review of clinical features, pathology and outcome was undertaken.

RESULTS

Surgical intervention was required for the following pancreatic disorders: persistent hyperinsulinemic hypoglycemia of infancy (n = 4), pancreatic tumors (n = 5), pancreaticobiliary malunion (n = 12), pancreatic trauma (n = 6) and pancreatitis (n = 10). The indications for surgery in acute pancreatitis were a persistent pseudocyst (n = 1) and treatment of an underlying cause of pancreatitis (n = 4); in chronic pancreatitis, surgery was used to treat symptomatic pancreatic duct strictures (n = 4). One child died of a progressive lymphoma but all others who underwent surgery are alive and well. All 33 children with acute pancreatitis, including four with pancreatic necrosis, survived.

CONCLUSIONS

Surgery for pancreatic disorders in children is rarely required but may be necessary a) for definitive management of primary pancreatic pathology, b) to treat sequelae of acute or chronic pancreatitis and c) to treat an underlying cause of pancreatitis. There is a broad spectrum of potential pathologies. These patients are best managed by a multidisciplinary team approach.

Idiopathic benign biliary strictures in surgically resected patients with presumed cholangiocarcinoma

OBJECTIVE

Distinguishing between malignant and benign biliary strictures remains problematic. The aim of this study was to compare and contrast the clinical features of patients with benign and malignant biliary strictures.

METHODS

Medical records of patients who underwent surgical resection for presumed cholangiocarcinoma were reviewed. Immunohistochemistry for hypoxia inducible factor-1-alpha (HIF-1-alpha) was performed on all bile ductule samples.

RESULTS

Twelve patients with benign strictures (group I) were compared to 26 patients with cholangiocarcinoma (group II). Group I was predominantly female (ratio 2: 1), (p<0.01), whereas the gender ratio was 1: 1 in patients in group II. Bismuth-Corlette type strictures in group I were more likely to be type I/II, whereas type III strictures predominated in group II. The CA 19-9 was <100 U/ml in 6 and >100 U/ml in 1 patient of group I and <100 in 13 and >100 in 11 patients in group II. Half of the patients in group I had positive immunoreactivity for HIF-1-alpha in bile ductules.

CONCLUSION

Benign biliary strictures masquerading as cholangiocarcinomas occur more often in women, are less often Bismuth-Corlette type III, have serum CA 19-9 values <100 U/ml, and hypoxia may play a role in a subset of these strictures.