Obstructive Jaundice Caused by Primary Duodenal Lymphoma

Gastrointestinal lymphomas account for approximately 40% of all extranodal lymphomas and for 4–12% of all nonHodgkin lymphomas [1–3] . The incidence has been reported to be 0.8–1.2 per 100,000 persons per year [4] . By far the most common site of primary gastrointestinal lymphoma is the stomach, accounting for 75– 80% of all primary gastrointestinal lymphomas, followed by the ileum (12–15%) and colorectum (approx. 5%). The duodenum only accounts for 0.8–2% of all gastrointestinal lymphomas [1, 5] . Symptoms most often associated with primary lymphoma of the small intestine include abdominal pain, anorexia, weight loss and manifestations of bowel obstruction. Less often observed are nausea, vomiting or diarrhea and only rarely gastrointestinal bleeding, and obstructive jaundice Dear Sir, Primary duodenal lymphoma is a rare neoplasm, and initial presentation with obstructive jaundice is even rarer. Primary B-cell lymphoma of the duodenum was shown to be the cause of biliary obstruction in the present case. A 70-year-old woman was referred to our hospital in July 2005 because of pruritic jaundice and dyspepsia for a few days. There was no weight loss, fever or nocturnal sweats. The patient had a history of bronchoalveolar adenocarcinoma (pT1pN0) for which she had had a resection of the left lower pulmonary lobe 4 years ago. Physical examination on admission was normal apart from jaundice. Abnormal laboratory findings included bilirubin 154 mol/l (normal value ! 20), alkaline phosphatase 547 IU/l ( ! 117), and ALT 284 IU/l ( ! 31); LDH was normal. CT scan showed dilated biliary and pancreatic ducts and a slight thickening of the duodenal wall without pancreatic or peripancreatic mass. Endoscopic retrograde cholangiography revealed an ulcerative tumor in the descending part of the duodenum including the papilla of Vater. There was massive dilatation of the biliary and pancreatic ducts with a stenotic section of about 3 cm in length in the distal common bile duct. A sphincterotomy was performed, and two 7Fr plastic double pigtail stents were placed and later replaced by a single 10-mm selfexpanding metal stent. Unexpectedly, hisPublished online: June 29, 2007