Lymphoma

Clinical

Lymphoma, because of its ability to affect lymphoid tissue throughout the body, as well as its ability to “do anything and go anywhere,” is difficult to exclude from any differential diagnosis. The answer to the question, “Could this be lymphoma?” is almost invariably, “Yes.”  This holds true for the small bowel. The small bowel is the most-often affected intestinal site of lymphoma, usually representing secondary involvement of non-Hodgkin’s lymphoma. It most often affects the distal ileum, because if its predominance of lymphoid tissue (remember Peyer’s patches?). There is an increased risk in patients with celiac disease or immunodifficiency. As expected by its spectrum of appearances, it has an extremely variable clinical presentation.

Radiological

On imaging studies, lymphoma has the “squirrelly” ability take on just about any radiographic appearance.  Its grocery-list appearance includes fold thickening and effacement, luminal narrowing, aneurysmal bowel wall dilatation, diffuse nodularity, extrinsic compression from mesenteric masses, solitary or multiple filling defects, ulceration, intussusception, to name a few. (There is no need to memorize this list, as you will notice it pretty much encompasses the entire gamut of small bowel disease processes.)

If your brain is running out of room for information (like mine), you may find it easier to just add lymphoma to all of your differential diagnosis lists.

Diffuse, irregular fold thickening in lymphocytic lymphoma.

Multiple filling defects in lymphocytic lymphoma.  The arrows point out the defects. Note the “target” appearance of the lesions, consistent with malignancy

Ulceration in histiocytic lymphoma.  Note also the luminal narrowing and fold thickening.