P1946 - Beyond the Expected: Primary Jejunal Lymphoma Masquerading as Occult Gastrointestinal Bleeding

Jorge Pacheco, ¹, Ninoska Meléndez, ¹, Lucy Celeste Estrada Ramírez, ², Brandom Steve Lobos Ortiz, ², Abel Sanchez, MD, MSc³
11. Gastroenterology and Endoscopy Unit, Hospital Roosevelt Guatemala, Guatemala City, Quetzaltenango, Guatemala; 22. Department of Radiology and Imaging diagnostics, Hospital Roosevelt, Guatemala, Guatemala City, Chimaltenango, Guatemala; 3Hospital Roosevelt / Gastri-k, Guatemala City, San Marcos, Guatemala

Introduction: Primary jejunal lymphoma is a rare gastrointestinal malignancy that often presents with nonspecific symptoms, leading to diagnostic delays. Patients may experience progressive fatigue, weight loss, intermittent abdominal pain, nausea, and altered bowel habits, making early detection challenging. While gastrointestinal lymphomas are more frequently diagnosed in older male patients, this case highlights an atypical presentation in a young female with persistent anemia and occult bleeding, emphasizing the need for heightened clinical suspicion in similar scenarios

Case Description/

Methods: A 16-year-old female with a history of progressive fatigue presented for evaluation. Laboratory studies revealed severe iron-deficiency anemia (Hb 7.1 g/dL) without overt gastrointestinal bleeding, raising suspicion for occult blood loss. Upper and lower endoscopy were unremarkable, leading to capsule endoscopy, which demonstrated ulcerated mucosa with active bleeding in the proximal jejunum. Due to the persistent anemia and inaccessible location of the lesion, the patient was taken to surgery, where an exploratory laparotomy was performed. Findings revealed an 80 cm segment of infiltrative disease with mesenteric extension and partial intestinal obstruction. Histopathological analysis confirmed diffuse large B-cell lymphoma (DLBCL), prompting initiation of R-CHOP chemotherapy

Discussion: This case highlights the atypical presentation of primary jejunal lymphoma, considering the patient’s young age, female sex, nonspecific symptoms, and jejunal involvement. Gastrointestinal lymphomas are uncommon, and even rarer in the proximal small intestine, making the diagnosis particularly challenging. The absence of overt gastrointestinal symptoms and the reliance on indirect signs, such as progressive fatigue and unexplained anemia, further complicated early detection.

Recognizing these unusual clinical features is essential for timely diagnosis and intervention. In patients with persistent anemia and vague systemic symptoms, clinicians should maintain a high index of suspicion for rare gastrointestinal malignancies, even in atypical demographics. This case underscores the need to expand differential considerations beyond common etiologies, ensuring patients receive appropriate oncologic management without unnecessary delays


Figure: Figure 1. A, B, C: Capsule endoscopy, which demonstrated multiple areas of ulcerated mucosa with active bleeding in the proximal jejunum; D, E, F: CT imaging revealing a 19.3 cm segment of circumferential thickening, suggesting an infiltrative process


Figure: Figure 2. A. At 10X magnification, a malignant lymphoproliferative lesion with a solid pattern can be observed. B. At a higher magnification of 40X, cellular characteristics become evident, showing large, monotonous cells with a loss of nucleus-to-cytoplasm ratio in favor of the nucleus. C. CD20+ indicating a B-cell membrane marker. D. Ki-67 proliferation index is positive, present in 95% of cells, indicating high proliferative activity.
E. TDT staining is positive, identifying a nuclear marker expressed in most lymphoid neoplasms

Disclosures:
Jorge Pacheco indicated no relevant financial relationships.
Ninoska Meléndez indicated no relevant financial relationships.
Lucy Celeste Estrada Ramírez indicated no relevant financial relationships.
Brandom Steve Lobos Ortiz indicated no relevant financial relationships.
Abel Sanchez indicated no relevant financial relationships.

Jorge Pacheco, ¹, Ninoska Meléndez, ¹, Lucy Celeste Estrada Ramírez, ², Brandom Steve Lobos Ortiz, ², Abel Sanchez, MD, MSc³. P1946 - Beyond the Expected: Primary Jejunal Lymphoma Masquerading as Occult Gastrointestinal Bleeding, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.