潰瘍症狀潛在初發性空腸濾泡性淋巴瘤–病例報告

Ulcer Symptoms Concealing Primary Jejunal Follicular Lymphoma: A Case Report

胃腸道淋巴瘤的臨床表現多樣且非特異，往往難以區分良性或惡性。內視鏡和放射學檢查的表現也不具特定性。在胃腸道，淋巴瘤是一種相對罕見的腫瘤，佔胃腸道惡性腫瘤的1%–8%，初發性胃、小腸和十二指腸淋巴瘤的比例約為10:3:1。濾泡性淋巴瘤主要發生在十二指腸，瀰漫性大B細胞淋巴瘤在胃和迴腸，黏膜相關淋巴組織淋巴瘤在胃，套細胞淋巴瘤在末端迴腸、空腸和結腸，而腸病相關T細胞淋巴瘤多在空腸。對於濾泡性淋巴瘤，觀察也是一種選擇，手術介入通常僅適於複雜的臨床狀況，如腸阻塞或穿孔。

本篇病例報告一位74歲男性個案，十八年前出現反覆性上腹痛、腹部脹氣、打嗝、腹瀉，偶有便秘，多次上消化道內視鏡檢查診斷胃與十二指腸潰瘍，治療後症狀仍然存在。兩年後出現嘔吐，全套血液、生化、糞便檢驗皆無異常，上消化道內視鏡顯示多發性胃與十二指腸潰瘍，無幽門桿菌感染。腹部超音波顯示明顯胃擴張，電腦斷層檢查未發現腸阻塞或狹窄。小腸鏡顯示第三至第四部分十二指腸狹窄，組織切片為B細胞型態淋巴瘤。個案接受手術，術中發現在屈氏韌帶下方約5 cm處近端空腸有一4.8 cm × 3.0 cm × 1.3 cm環狀腫瘤併腸繫膜數顆腫大淋巴結，予以切除9.8 cm空腸與淋巴結並接受腸道吻合。病理診斷為第2級濾泡性淋巴瘤。術後接受化學治療及定期追蹤。至今已過十六年，病人情況良好。定期追蹤檢查並無復發。

藉此病例報告提醒基層醫師面對反覆性消化性潰瘍時，必需將消化道淋巴瘤列入鑑別診斷。

 

It is challenging to distinguish benign gastrointestinal tumors from malignant ones due to their diverse and nonspecific symptoms, and endoscopic and radiological findings often lack specificity. Lymphoma is relatively uncommon in the gastrointestinal tract, constituting 1%-8% of malignant tumors with a primary tumor ratio of approximately 10:3:1 for the stomach, small intestine, and duodenum. Follicular lymphomas mainly occur in duodenum, diffuse large B-cell lymphomas in stomach and ileum, MALT lymphomas in stomach, mantle cell lymphomas in terminal ileum, jejunum, and colon, and enteropathy-associated T-cell lymphomas in jejunum. For the treatment of follicular lymphomas, observation remains a viable option, while surgical intervention is usually reserved for complicated clinical conditions, such as intestinal obstruction or perforation.

This case report features a 74-year-old male with recurrent epigastric pain, abdominal distention, hiccups, diarrhea and occasional constipation since he was diagnosed with duodenal ulcers eighteen years ago. Repeated panendoscopic examinations showed gastric and duodenal ulcers. Symptoms persisted after treatment and were followed by vomiting two years later. Comprehensive blood, biochemical, and stool analyses revealed no abnormalities. Panendoscopic examination showed multiple ulcers in the stomach and duodenum without Helicobacter pylori infection. Abdominal ultrasound indicated significant gastric dilation, and computed tomography scan revealed neither intestinal obstruction nor stenosis. Small intestinal fiberscope found stenosis in the third to fourth portions of the duodenum, and tissue biopsy suggested B-cell lymphoma. Intraoperatively, a circumferential tumor measuring 4.8 cm × 3.0 cm × 1.3 cm was identified, located approximately 5 cm proximal to the Ligament of Treitz. It was accompanied by enlarged mesenteric lymph nodes. The excision of 9.8 cm of the jejunum, along with lymph node dissection, was followed by anastomosis. Surgical pathology confirmed grade II follicular lymphoma. Postoperatively, the patient receives chemotherapy and undergoes regular follow-up. The patient has remained in good medical condition over these sixteen years. Follow-up examinations did not show tumor recurrence. This case report aims to remind primary care physicians to consider gastrointestinal lymphoma early in the differential diagnosis of recurrent peptic ulcers.