A286 OVERT GI BLEED DUE TO CHRONIC LYMPHOCYTIC LEUKEMIA INFILTRATION IN THE SMALL BOWEL

Patients with leukemic infiltrates in the gastrointestinal tract are usually asymptomatic but may present with abdominal pain, diarrhea, or GI bleeding. We aim to report a case of GI bleed caused by chronic lymphocytic leukemia (CLL) infiltrating the small bowel. Case report and review of literature. An 89-year-old man with history of CLL that was treated six years ago, low-grade bladder cancer and left leg deep vein thrombosis on therapeutic low-molecular weight heparin (LMWH) presented with a 2-week history of melena stool. He reported 1 melena stool per day but denied hematemesis or hematochezia. He experienced intermittent left lower quadrant abdominal pain and worsening fatigue. Physical exam was unremarkable with normal digital rectal exam. Hemoglobin was decreased to 60 g/L from a baseline of 111 g/L 2 months ago. White blood cell (WBC) was 238 x 109/L with lymphocyte of 228 x 109/L, which was similar to baseline levels. Esophagogastroduodenoscopy and colonoscopy did not reveal source of bleeding. Video capsule endoscopy showed multiple small bowel lymphangiectasia with red spots at small-bowel transit time ratio of 14%, 28%, 44%, and 45%. The lesion at 14% appeared to have a centralized erosion which might have been the culprit lesion (Figure 1A). These lesions were biopsied using double balloon enteroscopy. Tissue histology showed fragments of monotonous lymphocytic cell population (Figure 1B) which were positive for CD5, CD20 and CD23 in keeping with CLL infiltration (Figure 1C). LMWH was stopped and he began treatment with ibrutinib, this led to resolution of his GI symptoms. CLL is the most prevalent form of leukemia in adults, complications are usually associated with intrinsic immune dysfunction resulting in infection, anemia, and thrombocytopenia. CLL has been reported to infiltrate throughout the GI tract, however clinically significant GI infiltration by CLL is rare. The few cases reported in the literature are limited to the terminal ileum and proximal colon causing GI bleed, abdominal pain and obstruction. This is the first case reported to show that CLL can also affect multiple segments of the small bowel to cause overt GI bleed, likely due to formation of lymphangiectasia or vascular ectasia. Although CLL in the small bowel is rare, physicians should consider this in formulating a differential diagnosis in patients with CLL and unexplained GI bleeds. Figure 1. Multiple small bowel lymphangiectasia with red spots were seen with video capsule endoscopy at small-bowel transit time ratio of 14%, 28%, 44%, and 45%. A) The lesion at 14% appeared to have a centralized erosion. B) High power view at x200 magnification shows hemorrhagic tissue mixed with small bowel epithelium and bland monomorphic lymphocytic cell population. C) Immunohistochemistry for CD20, CD5 and CD23 respectively in keeping with diagnosis of CLL. None

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