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Scientific letter
Intestinal perforation secondary to intestinal diffuse large b-cell lymphoma in a patient with coeliac disease
Perforación intestinal secundaria a linfoma intestinal B difuso de células grandes en un paciente con enfermedad celiaca
Raquel Ríos Leóna,
Corresponding author
raquelriosleon@gmail.com

Corresponding author.
, Laura Crespo Péreza, Carla Martínez-Geijo Románb, Ana Barbado Canoc, Mónica García-Cosío Piquerasd, Eugenia Sánchez Rodrígueza, Irene García de la Filia Molinaa, Álvaro Flores de Miguela, Antonio Guerrero Garcíaa, Francisco Javier López-Jiménezb, Antonio Mena Mateose, Agustín Albillos Martíneza
a Servicio de Gastroenterología, Hospital Universitario Ramón y Cajal, Madrid, Spain
b Servicio de Hematología, Hospital Universitario Ramón y Cajal, Madrid, Spain
c Servicio de Gastroenterología, Hospital Universitario La Paz, Madrid, Spain
d Servicio de Anatomía Patológica, Hospital Universitario Ramón y Cajal, Madrid, Spain
e Servicio de Cirugía General y Digestivo, Hospital Universitario Ramón y Cajal, Madrid, Spain
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      "es" => array:1 [
        "titulo" => "Perforaci&#243;n intestinal secundaria a linfoma intestinal B difuso de c&#233;lulas grandes en un paciente con enfermedad celiaca"
      ]
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Abdominal CT showing the intestinal perforation in the jejunum &#40;arrow&#41;&#46; &#40;B&#41; Histological analysis of the surgically resected jejunal loop&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with coeliac disease have an increased risk of gastrointestinal lymphomas&#44; although the overall incidence is very low&#46; We present the case of a 36-year-old man with a history of Down&#39;s syndrome&#44; type 1 diabetes and coeliac disease &#40;CD&#41; diagnosed in childhood&#44; with good adherence to the gluten-free diet&#44; without data to suggest malabsorption and negative coeliac antibodies&#46; In the follow-up biopsy at the age of 19&#44; Marsh 3a villous atrophy persisted&#44; and lymphogram by flow cytometry was compatible with active CD&#44; but without an aberrant lymphocyte population&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient attended the hospital with progressively worsening diffuse abdominal pain associated with nausea and vomiting&#46; Abdominal examination found signs of peritoneal irritation&#46; Blood tests showed glucose 317<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and venous pH 7&#46;32&#44; with no anaemia or leucocytosis&#46; Contrast-enhanced abdominal&#47;pelvic CT scan showed pneumoperitoneum&#44; free intra-peritoneal fluid and a dilated jejunal loop&#44; the wall of which was circumferentially thickened&#44; with a tumour-like appearance and adjacent extraluminal gas bubbles &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Also detected was lymphadenopathy involving multiple lymph nodes in the root of the mesentery and a thickening of a long segment of sigmoid colon&#46; As perforation was suspected&#44; a laparotomy was performed with resection of the proximal jejunum and primary anastomosis and a sigmoidectomy with terminal colostomy&#46; The histological analysis was compatible with intestinal diffuse large B-cell lymphoma of activated phenotype affecting the mucosa&#44; causing ulceration of the mucosa&#44; the muscle wall and the underlying fat&#44; with no lymph node involvement &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; Bone marrow biopsy ruled out neoplastic infiltration and Epstein Barr virus was negative&#46; The patient received six cycles of CHOP-R &#40;cyclophosphamide&#44; doxorubicin&#44; vincristine&#44; prednisone and rituximab&#41; to treat the lymphoma&#46; Restoration of intestinal transit was subsequently performed with colon-sigmoid anastomosis&#46; Follow-up PET-CT and abdominal CT scans at 18 months detected no evidence of tumour recurrence&#46; The patient is currently well&#44; with good adherence to the gluten-free diet and periodic follow-up of his CD&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Primary small bowel tumours account for less than 2&#37; of all gastrointestinal cancers&#44; and lymphomas account for 15&#8211;20&#37; of them &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The gastrointestinal tract is the most common site for lymphomas to have extranodal involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In primary gastrointestinal lymphomas&#44; the organ most commonly affected is the stomach&#44; followed by the small intestine &#40;60&#8211;65&#37; affect the ileum and the rest the jejunum and duodenum&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Almost 90&#37; are B-cell lymphomas&#44; the most common subtypes being diffuse large B-cell lymphoma and extranodal marginal zone B-cell mucosa-associated lymphoid tissue &#40;MALT&#41; lymphoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> They may present with abdominal pain&#44; vomiting&#44; weight loss and&#44; rarely&#44; as obstruction&#44; intussusception&#44; perforation &#40;5&#8211;15&#37;&#41;&#44; gastrointestinal haemorrhage or diarrhoea&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> Most lymphomas are treated with a combination of surgery and chemotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> The tumour stage and the presence of B symptoms are associated with a worse prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients with CD have a 40&#37; higher risk of developing any cancer compared to the general population&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> and are five times more likely to develop a lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The cancer type most commonly associated with CD is non-Hodgkin&#39;s lymphoma&#44; with an incidence of 1&#46;3 per 1000<span class="elsevierStyleHsp" style=""></span>person-years&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Of these&#44; the most common are diffuse large B-cell lymphoma and enteropathy-associated T-cell lymphoma&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;5</span></a> Although no differences have been found in the survival of patients with CD and a lymphoproliferative process with respect to the general population&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> B-cell lymphomas have a better prognosis than T-cell lymphomas&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The most common gastrointestinal cancers to be associated with CD are adenocarcinoma of the small intestine&#44; cancer of the oesophagus and colorectal cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Enteropathy-associated T-cell lymphoma is the lymphoma most closely associated with CD&#46; This is a high-grade non-Hodgkin&#39;s lymphoma which accounts for less than 5&#37; of gastrointestinal lymphomas and is usually found in primary form in the small intestine&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The overall risk of malignancy in patients with CD decreases with time after diagnosis and does not increase significantly after 15 years&#44; probably thanks to early diagnosis and early introduction of the gluten-free diet&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;7</span></a> Following a gluten-free diet aids healing of the mucosa&#44; but&#44; in almost 20&#37; of cases&#44; villous atrophy is found in the follow-up biopsy&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;9</span></a> In cases in which villous atrophy persists&#44; there is twice the risk of developing a lymphoproliferative process than in those with mucosal healing&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In Down&#39;s syndrome there is an increased risk of death compared to the general population&#44; due mainly to cardiac malformations&#44; early-onset dementia and childhood leukaemia&#46; People with Down&#39;s syndrome also have a six-fold higher risk of suffering from CD&#44; although the association between the two diseases does not lead to an increase in mortality rates compared to the rest of the population with Down&#39;s syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; properly following a gluten-free diet decreases the risk of developing a lymphoma and any other cancer associated with CD&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;7</span></a></p></span>"
    "pdfFichero" => "main.pdf"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; R&#237;os Le&#243;n R&#44; Crespo P&#233;rez L&#44; Mart&#237;nez-Geijo Rom&#225;n C&#44; Barbado Cano A&#44; Garc&#237;a-Cos&#237;o Piqueras M&#44; S&#225;nchez Rodr&#237;guez E&#44; et al&#46; Perforaci&#243;n intestinal secundaria a linfoma intestinal B difuso de c&#233;lulas grandes en un paciente con enfermedad celiaca&#46; Gastroenterol Hepatol&#46; 2018&#59;41&#58;503&#8211;504&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Abdominal CT showing the intestinal perforation in the jejunum &#40;arrow&#41;&#46; &#40;B&#41; Histological analysis of the surgically resected jejunal loop&#46;</p>"
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          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Ghimire et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> and Koch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a></p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Gastrointestinal lymphomas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Oesophagus &#40;&#60;1&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Gastric &#40;68&#8211;75&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Extranodal marginal zone B-cell MALT lymphoma &#40;38&#8211;48&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diffuse large B-cell lymphoma &#40;45&#8211;59&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Others&#58; mantle cell lymphoma&#44; follicular lymphoma&#44; peripheral T-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Small intestine &#40;20&#8211;30&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Extranodal marginal zone B-cell MALT lymphoma &#40;30&#8211;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diffuse large B-cell lymphoma &#40;50&#8211;55&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Enteropathy-associated intestinal T-cell lymphoma &#40;10&#8211;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Immunoproliferative small intestinal disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Others&#58; follicular lymphoma&#44; mantle cell lymphoma&#44; Burkitt lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Colorectal &#40;3&#8211;6&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mantle cell lymphoma&#44; follicular lymphoma&#44; diffuse large B-cell lymphoma&#44; MALT lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Frequency of gastrointestinal lymphomas according to the affected region of the gastrointestinal tract&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
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