Perforated ileal phytobezoar revealed a MALT lymphoma

Abstract

A 45-year-old woman was under study for one year of abdominal
pain associated with 4kg weight loss and chronic constipation. An
entero magnetic resonance found a mass of 8x10cm on medium
ileum suggesting a phytobezoar, with no proximal bowel dilatation.
The woman was scheduled for programmed resection. Two weeks
after, she presented on our emergency department with an acute
abdomen. Exploratory laparotomy showed a bowel perforation of
the phytobezoar, and a segmental resection was performed. No
more bezoars were found on exploration. She did well after surgery
and was discharged home on 6th post-operative day. Pathology
revealed a MALT Lymphoma (cells were CD20-positive Blymphocytes
that co-expressed BCL-2 and were negative for CD3,
CD5, CD10, CD23, BCL-6 and cyclin D1 on immunohistochemical
studies). The overall proliferation index was low with Ki-67
immunoreactivity in approximately 10% of cells. The bone marrow
biopsy showed no evidence of involvement by lymphoma. The
patient started therapy with rituximab infusions (monoclonal
antibody against CD20). In two years follow up she remains
asymptomatic and without recurrence. Primary ileal MALT
lymphoma is rare, and has not been associated with a specific
infectious disease. Bezoar is an unusual cause of small bowel
obstruction accounting for 0.4-4% of all mechanical bowel
obstruction. The common site of obstruction is terminal ileum. We
believe that the primary MALT lymphoma caused a small mechanic
obstacle that made alimentary fibers to accumulate and cause the
phytobezoar. The perforation required a segmental resection, which
finally led to the diagnostic of the MALT lymphoma.