Diffuse Large B-Cell Non-Hodgkin Lymphoma Presenting as Acute Pancreatitis

Mild intrahepatic biliary dilatation was also noted as a secondary finding, which corresponded with elevated liver function test (LFT) values (alkaline phosphatase, 764 U/L; alanine aminotransferase, 425 U/L; aspartate aminotransferase, 288 U/L). The white blood cell count was elevated at 13.0 million/µL (reference range, 3800-10,800/µL).

The patient was started on intravenous normal saline and made nil per os. Gastroenterology and general surgery consults were obtained, and the patient was admitted to the hospital. Magnetic resonance imaging and ultrasonography of the abdomen showed a markedly enlarged pancreas with severe surrounding inflammatory changes and free fluid. An upper gastrointestinal radiography series revealed no evidence of small bowel obstruction. Lipase and amylase levels continued to be elevated.

To compound the CT finding of intrahepatic biliary dilatation, LFT values and bilirubin levels were persistently elevated. In an effort to find the source of the liver pathology, a hepatitis panel was ordered to screen for hepatitis A, B, and C; results were nonreactive.

Abdominal ultrasonography showed moderate ascites, with the largest pocket of fluid present in the pelvic region. Due to his history of cholecystectomy, nuclear medicine testing of the liver and gallbladder was not pursued. An interventional radiologist was consulted, who proceeded to a percutaneous transhepatic cholangiogram (PTC) with stent placement, which resulted in the draining of 2.8 L of brownish yellow fluid over 24 hours. After the PTC procedure, LFT values and bilirubin levels began to rapidly trend downward until plateauing at mildly elevated levels.

After 10 days of medical management and daily serial CT scans, the pancreatitis had not improved and continued to worsen. CT scans continued to show a progressive enlargement of the pancreatitis; however, there were no signs of necrosis within the pancreas. The patient began having severe dyspnea on day 14; chest radiographs showed an elevation of the right hemidiaphragm due to pleural effusion and increased abdominal pressure. Thoracentesis was performed, draining 1.4 L of serosanguinous fluid, but this provided only minimal relief to the patient. Due to worsening abdominal distension, paracentesis was performed as an attempt to relieve the pressure. Ascitic and pleural fluid were sent for pathological analysis, and bladder pressures were obtained to monitor for abdominal compartment syndrome. Bladder pressures remained at 13 cm H₂O, ruling out compartment syndrome.

The ascitic fluid pathology report showed malignant cells consistent with high-grade non-Hodgkin lymphoma (NHL) (Figures 2 and 3).

Figures 2 and 3. Ascitic fluid pathology results were consistent with high-grade NHL.

At this point, a hematologist/oncologist was consulted, and a bone marrow biopsy was performed with the purpose of determining the extent and staging of the lymphoma. The bone marrow biopsy pathology report showed extensive involvement by non-Hodgkin high-grade B-cell lymphoma and a monotypic B-cell population with CD-10 coexpression (Figure 4).

Figure 4. Bone marrow biopsy results showed extensive involvement by non-Hodgkin high-grade B-cell lymphoma and a monotypic B-cell population with CD-10 coexpression.

The patient was started on a cycle of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone and was discharged with continued chemotherapy and outpatient monitoring planned by the hematologist/oncologist.