A 48-year-old man was referred to our hospital because of intermittent abdominal pain
and chronic diarrhea for 2 months and acute massive upper gastrointestinal bleeding,
which had commenced a few days ago. Esophagogastroduodenoscopy (EGD) showed an ulcerating
mass in the second part of the duodenum, located just beyond the ampulla ([Fig. 1 ]). The bleeding was successfully stopped by injecting epinephrine into the tumor
followed by spraying with Histoacryl [1 ] ([Fig. 2 ]). A few days after the procedure the patient developed acute, severe abdominal pain
and nausea and vomiting. Computed tomography (CT) showed intussusception of two long
segments of the ileum associated with multiple intraluminal masses. The first segment
was in the jejunum and the second was ileocolic intussusception ([Fig. 3 ]). There were also multiple bony metastases and lymphadenopathy in the paravertebral
region. A biopsy sample from the duodenum showed hematological malignancy with plasmacytic
differentiation, and was positive for CD45, CD138, c-lambda, and c-kappa, and negative
for CD20, CD30, and CD3 ([Fig. 4 ]). The bone marrow biopsy was compatible with multiple myeloma. After treatment with
intravenous chemotherapy, the patient’s clinical condition improved and the abdominal
pain as well as small-bowel obstruction disappeared a few days later.
Fig. 1 Endoscopic view of a duodenal mass in a 48-year-old with intermittent abdominal pain,
chronic diarrhea, and acute massive upper gastrointestinal bleeding.
Fig. 2 Bleeding stopped after spraying Histoacryl.
Fig. 3 Computed tomography (CT) showing the two sites of small-bowel intussusception.
Fig. 4 a Histopathological section showing atypical cells with vesicular nuclei, prominent
nucleoli and amphophilic cytoplasm. b The sample stained positive for CD138.
Abnormalities in B-cell transformation result in the development of an aberrant or
malignant plasma cell called the plasmablast. These cells can proliferate in the bone
marrow, giving rise to multiple myeloma or primary extramedullary plasmacytoma, which
is a rare form of the disease [2 ]. Extramedullary plasmacytoma accounts for 20 % of plasmablast-related diseases but
only 7 % of cases involve the gastrointestinal tract. The most commonly involved organs,
in the order of decreasing frequency, are the stomach, jejunum, ileum, colon, and
rectum [3 ]. Duodenal involvement is rare [2 ]
[3 ]
[4 ]
[5 ]. Endoscopic findings in plasmacytoma show no specific characteristics: it may manifest
as discrete ulcers, ulcerating mass, thickening of the mucosal fold, or even as a
mucosal polyp [2 ]. The differential diagnoses are duodenal lymphoma, adenocarcinoma of the duodenum,
and pancreatic head cancer invading the duodenum. Hence the final diagnosis is based
on the histopathology and immunohistochemistry.
Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AB
