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Intest Res > Volume 15(2); 2017 > Article
Zhang, Li, You, Ni, Zhang, and Qian: An ileosigmoid fistula: what is the diagnosis?

Question

ir-15-260-g001.jpg
A 43-year-old man presented with diarrhea and hematochezia for 1 month prior to hospitalization. He had moderate fever, iron-deficiency anemia, and weight loss of 5 kg in the previous 2 weeks. Physical examination revealed a malnutrition status with a body weight index of 17.5 kg/m2. Neither superficial lymphadenopathy nor hepatosplenomegaly was found.
Contrast-enhanced CT of the abdomen revealed the thickened wall of the distal sigmoid colon, an ileosigmoid fistula (Fig. A), and lymphadenopathy in the abdomen and pelvis with a maximum measurement of 4.0×2.6 cm. Barium enema revealed the two paths around the rectosigmoid junction. One was the usual sigmoid colon with remarkable mucosal abnormalities. The other was the ileosigmoid fistula with an irregular lumen (Fig. B). Colonoscopy also clearly revealed a huge ileosigmoid fistula and ulcerative lesions at the rectosigmoid junction (Fig. C). What is your diagnosis of this unusual fistula?

Answer to the Images: Non-Hodgkin's Lymphoma

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Biopsy specimens were taken from the ulcerative lesions. Pathological examination revealed diffuse infiltration of large lymphoid cells with irregular enlarged nuclei and prominent nucleoli in the mucosa and submucosa (Fig. D, H&E, ×100, and E, H&E, ×400). Immunochemical examination revealed that these atypical cells were strongly positive for CD20 and PAX-5, and negative for CD3 and CD30, and had a high Ki-67 index 80%; which supported the diagnosis of diffuse large B cell lymphoma. Furthermore, the tumor was categorized into the immunochemical subgroup, non-germinal center B type, according to Mum-1 (Fig. F, ×200) and Bcl-6 (Fig. G, ×200) expressions in nuclei and no reaction to CD10 (Fig. H, ×200).
The common causes of internal GI fistulas are CD, diverticulitis, cancer, and iatrogenic injury.1 Primary GI non-Hodgkin's lymphoma involves the stomach (approximately 70%), small bowel (9%), and ileocecal region (7%).2 Intestinal fistula associated with lymphoma is rare. Intestinal perforation can occur spontaneously, act as a surgical complication, or arise from the regressive changes after chemotherapy, which may result in chronic GI fistulas occasionally. Primary GI fistulas that communicate with the guts and various adjacent organs have also been documented, including the bronchus, bladder, spleen, and even aorta.3,4,5
In our patient, chronic ileosigmoid fistula was clearly detected by using CT, barium enema, and colonoscopy. The histopathological examination of the specimens from the ulcerative lesions was critical to the diagnosis of non-Hodgkin's lymphoma. The patient was then transferred to the hematology department to receive chemotherapy.

NOTES

Financial support: None.

Conflict of interest: None.

References

1. Pickhardt PJ, Bhalla S, Balfe DM. Acquired gastrointestinal fistulas: classification, etiologies, and imaging evaluation. Radiology 2002;224:9-23.PMID: 12091657.
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2. Koch P, del Valle F, Berdel WE, et al. Primary gastrointestinal non-Hodgkin's lymphoma: I. anatomic and histologic distribution, clinical features, and survival data of 371 patients registered in the German Multicenter Study GIT NHL 01/92. J Clin Oncol 2001;19:3861-3873.PMID: 11559724.
crossref pmid
3. Chun HB, Baek IH, Lee MS, et al. Jejunocolic fistula associated with an intestinal T cell lymphoma. Gut Liver 2011;5:387-390.PMID: 21927672.
crossref pmid pmc
4. Rigney D, Hall AB, McElveen R, de Delva PE. Healing of a large bronchoesophageal fistula secondary to Hodgkin lymphoma managed with a removable esophageal stent. Ann Thorac Surg 2013;96:2216-2219.PMID: 24296188.
crossref pmid
5. Shulik O, Marling K, Butler J. Primary aorto-enteric fistula: a unique complication of poorly differentiated large B-cell lymphoma. Am J Case Rep 2013;14:194-197.PMID: 23826466.
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