Development of early gastric cancer 4 and 5 years after complete remission of Helicobacter pylori associated gastric low grade marginal zone B cell lymphoma of MALT type.

AIM: To report 3 of 120 patients on the German MALT lymphoma trial with H. pylori associated gastric MALT lymphoma who developed early gastric cancer 4 and 5 years, after complete lymphoma remission following cure of H. pylori infection. PATIENTS AND RESULTS: Three patients (two men, 74 and 70 years; one women, 77 years) with H. pylori-associated low-grade MALT lymphoma achieved complete lymphoma remission after being cured. Surveillance endoscopies were performed twice a year in accordance to the protocol. Four years after complete lymphoma remission in two patients, and after 5 years in the other, early gastric adenocarcinoma of the mucosa-type, type IIa and type IIc, respectively, was detected, which were completely removed by endoscopic mucosa resection. In one patient, the gastric cancer was diagnosed at the same location as the previous MALT lymphoma, in the other patients it was detected at different sites of the stomach distant from location of the previous MALT lymphoma. The patients were H. pylori negative during the whole follow-up time. CONCLUSION: These findings strengthen the importance of regular Long-term follow-up endoscopies in patients with complete remission of gastric MALT lymphoma after cure of H. pylori infection. Furthermore, gastric adenocarcinoma may develop despite eradication of H. pylori.

[Giant fecaliths in habitual constipation]. / Riesenkotsteine bei habitueller Obstipation.

HISTORY AND FINDINGS: A 17-year old adolescent with chronic constipation developed fecal incontinence with liquid, fetid stool. He had had variable bowel symptoms since early childhood, but not in his infancy. Since several years he had undergone psychotherapeutic treatment for depression due to a familial conflict situation. Abdominal palpation revealed the presence of a large, hard mass in the lower abdomen, measuring about 20 cm in diameter. INVESTIGATIONS: A defecography verified the presence of a huge obstructing fecalith in the rectum, with massive dilation and elongation of the antecedent rectum and colon (megarectum and megacolon). Neither endoscopy nor radiological imaging revealed a narrow bowel segment. In sequential biopsies, no indication of aberrant innervation was found. The recto-anal inhibitory reflex could be elicited. TREATMENT AND COURSE: Restoration of the rectal passage was achieved by manual disimpaction in numerous sessions, supported by repeated rectal enemas. Subsequently, the patient had normal daily bowel movements for a few days. However, he had to be readmitted three weeks later because again a fecalith had formed, measuring 15 cm in diameter. A few days after discharge the patient hat not followed the exhortation to void ad least once per day. After renewed disimpaction he was referred to a psychosomatic clinic. CONCLUSION: Voluntary withholding of defecation can eventuate massive coprostasis and the development of megacolon and megarectum. In theses instances the major complaint may not be constipation but paradoxical diarrhea. A number of conditions have to be excluded before the diagnosis idiopathic megacolon can be confirmed. Treatment ist difficult and often necessitates prolonged and repetitious interventions.

[Unusual case of disseminated sarcoidosis with prominent gastrointestinal symptoms]. / Ungewöhnlicher Fall einer disseminierten Sarkoidose mit führender gastrointestinaler Symptomatik.

HISTORY AND ADMISSION FINDINGS: A 63-year-old man had for 10 months suffered from marked weight loss, night sweats, diffuse abdominal pain and increased stool frequency. He was admitted to evaluate an ultrasonically abnormal focus in the liver parenchyma and elevated liver function parameters. His sclerae were obviously icteric and he looked under-weight. INVESTIGATIONS: He had a hypochromic microcytic anemia and abnormal liver and pancreatic function tests: total bilirubin 3.11 mg/dl, direct bilirubin 2.21 mg/dl, GOT21U/l, gamma-GT 422 U/l, alkaline phosphatase 1449 U/l, alpha-amylase 481 U/l, lipase 2827 U/l. The serum creatinine level was elevated to 1.47 mg/dl. Computed tomography revealed enlarged liver and spleen as well as an enlargement of intraabdominal lymph nodes, chest radiogram and endoscopic cholangio-pancreatography were unremarkable. Biopsies from the lower duodenum, large intestine, bone marrow and liver showed inflammatory changes with Langhans-type mononuclear granulomas. Together with these findings an increased activity of the angiotensin-converting-enzyme (ACE) indicated sarcoidosis, other causes having been excluded. TREATMENT AND COURSE: All signs and symptoms rapidly improved under prednisolone, and 4 weeks after begin of treatment the biochemical abnormalities had clearly regressed. The raised serum levels of soluble IL-2 receptors and of neopterin, measures of sarcoidosis activity, had decreased. Activity of ACE had fallen. CONCLUSION: Sarcoidosis can present with diverse clinical signs and symptoms. In a case of multi-system disease that cannot be readily classified, sarcoidosis should be included in the differential diagnosis.

[MALT lymphoma of the ileum as the cause of an enterocolic invagination]. / MALT-Lymphom des Ileums als Ursache einer enterokolischen Invagination.

HISTORY AND FINDINGS: A 44-year-old woman who had moved to Germany from Kazakhstan 2 years previously developed right upper abdominal pain. A cylindrical mass was palpable in the area. There were strong intestinal sounds. INVESTIGATIONS: There was an iron-deficiency anaemia (haemoglobin 6.3 g/dl, serum iron 4 micrograms/dl) and occult blood was found in the stool. Coloscopy revealed a lumpy mass external to the transverse colon but fixed to it, partially obstructing the lumen. However, on contrast infusion the mass could be displaced in to the caecum, suggesting enterocolic invagination. TREATMENT AND COURSE: At operation the cause of the investigation was found to be a large jagged tumour of the terminal ileum. A right hemicolectomy and excision of the terminal ileum were performed. Histologically the tumour was a centroblastic non-Hodgkin lymphoma of the MALT type (mucosa-associated lymphatic tissue).