Journal of Surgical Case Reports, 2017;12, 1–3

doi: 10.1093/jscr/rjx249
Case Report

CASE REPORT

Endoscopic management of duodeno-ileal fistula

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secondary to diffuse B-cell lymphoma
James A. Milburn1,*, John S. Leeds2, and Steven A. White1
1
Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK and
2
Department Gastroenterology, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
*Correspondence address. Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK. Tel: +44-12-24-55-4169;
Fax: +44-12-24-55-1236; E-mail: [email protected]

Abstract
Lymphoma arising in the gastrointestinal tract is relatively common and can affect multiple sites. The development of a
gastrointestinal fistula secondary to lymphoma is very rare and has not previously been reported between the duodenum
and ileum. This is the first reported care where a fistula secondary to lymphoma has been treated by an endoscopic covered
duodenal stent occluding the defect rather than surgical intervention. This strategy permitted early commencement of cura-
tive intent chemotherapy which led to tumour shrinkage and fistula closure.

INTRODUCTION 8–10 watery stools per day which were noted to contain
recently ingested foodstuffs. Past medical history included
Primary gastrointestinal lymphoma (PGIL) accounts for 30–40% of
hypertension, diabetes, bronchiectasis and obesity. Four years
extra-nodal malignant lymphoma cases and up to 10–15% of all
previously he had undergone laparotomy for common bile duct
non-Hodgkin’s lymphoma (NHL) [1]. Temporal data series sug-
exploration and cholecystectomy through a supraduodenal
gest the incidence of PGIL is increasing in the Western world
approach. Prior endoscopic retrograde cholangiopancreatogra-
although the reasons are uncertain. Internal entero-entero fistu-
phy was unsuccessful due to multiple large calculi although no
lation between intestinal segments can be due to multiple aeti-
duodenal abnormalities were noted either before or after this
ologies although there are sparse reports of lymphoma as a
intervention.
primary cause. Experience with the endoscopic management of
Initial upper GI endoscopy failed to enter the duodenum due
upper gastrointestinal (GI) fistulas is limited as an operative
to residue within the stomach with the appearance and odour
intervention is often performed. We report the case of an 80-
of faeces noted. Abdominal computed tomography (CT) sug-
year-old man who presented with symptomssds attributable to a
gested a cavity with adherent ileum adjacent to the second part
duodeno-ileal fistula secondary to diffuse B-cell lymphoma lead-
of the duodenum (Fig. 1). A contrast study was then undertaken
ing to the first reported case of endoscopic management.
demonstrating rapid flow of contrast into the terminal ileum
and caecum originating from the duodenum (Fig. 2). Repeat
upper GI endoscopy demonstrated an abnormal fungating fistu-
CASE REPORT lous communication between the duodenum and terminal
An 80-year-old male presented to the emergency department ileum which permitted the full insertion of the endoscope (Figs
with worsening diarrhoea and faeculent vomiting on a back- 3 and 4). Biopsies were consistent with diffuse B-cell lymphoma
ground of significant weight loss and dyspepsia. He passed (DLBCL) in accordance with the WHO classification.

Received: September 22, 2017. Accepted: November 22, 2017

Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2017.
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1
 2 | J.A. Milburn et al.

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Figure 3: Endoscopic images of duodenum.

Figure 1: Computed tomography image of duodenal-ileal mass (arrow indicates

cavity).

Figure 4: Endoscopic image through duodenal fistula.

radiological and upper GI endoscopy showed sealing of the fis-

tula at 3 months. (Fig. 5) The patient was able to resume a full
oral diet when the stent was removed. Six months following
diagnosis the patient continues to do well with a good response
to chemotherapy with planned CT surveillance.

DISCUSSION
Figure 2: Oral contrast study showing transit of barium into the ileum from a
PGLI lymphoma can affect any segment of the GI tract with a
duodenal source through a cavity (arrow indicates cavity arising from
duodenum).
variety of pathological subtypes exhibiting a global variation.
The most frequent PGLI arise from proliferating peripheral B-
lymphocytes and over half lead to DLBCL [2]. In a Western
The patient was commenced on a combination of parenteral population approximately half of PGLI arise in the stomach,
nutrition with passage of a nasojejunal tube beyond the fistula with a quarter in the small intestine and 10% the colon, with
with cautious introduction of enteral feeding. He was assessed rare presentations in the oesophagus, liver or pancreas. Up to
for surgical intervention but due to his comorbidities this was 15% of patients will have multiple sites of involvement in the
considered very high risk. He therefore underwent insertion of GI tract [3].
a fully covered self expanding metal stent (60 × 20 mm2 duo- Haldane reported the first case of a malignant GI fistula due
denal stent, Tawoong Medical, South Korea) to cover the defect. to adenocarcinoma in 1862 while lymphoma was first impli-
He symptomatically improved and commenced com- cated as aetiology in 1946 [4, 5]. A 2005 review of the literature
bination chemotherapy (R-GCVP Rituximab, Gemciabine, concluded that <20 entero-entero fistulae secondary to lymph-
Cyclophosphamide, Vincristine and Prednisolone). Subsequent oma had been reported primarily treated surgically [6]. These
 Endoscopic management of duodeno-ileal fistula secondary | 3

vomiting. However, surgery remains advocated by some groups

especially for intestinal (non-gastric) tumours reporting improved
outcomes with adjuvant chemotherapy rather than chemother-
apy alone [3]. Furthermore, indolent tumour including Mantle or
Follicular subtypes where chemotherapy is less effective may also
benefit from resection [1].
In this case, surgery would have required a pancreaticoduo-
denectomy with a right hemicolectomy conferring a high risk
of mortality and morbidity in this elderly patient. Surgery was
avoided by the use of a covered duodenal stent which simul-
taneously excluded the defect allowing restoration of enteral
nutrition and allowed early introduction of chemotherapy

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agents avoiding delay to treatment in postoperative recovery.
The use of duodenal stents to treat fistulating conditions of the
GI tract including the duodenum has previously been reported
although often this is in palliative setting [10].
Our report has described the novel use of a duodenal stent
as bridging therapy to facilitate early introduction of chemo-
therapy in a complex patient. Advanced endoscopic techniques
can be a useful therapeutic modality in PGIL cases to avoid sur-
gery and improve outcomes.

Figure 5: Computed tomography image showing improvement in appearances

(stent removed).
CONFLICT OF INTEREST STATEMENT
None declared.
intra-abdominal internal lymphomatous fistulae are more
commonly jejuno-colic or gastro-colic [6, 7].
No previous cases of duodeno-ileal fistulae secondary to
PGLI have been reported in the literature suggesting this is the
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