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Tumor Discovery BrECADD-induced ileus and GI hemorrhage

Staging workup revealed advanced-stage HL with a large
mediastinal mass and associated pleural and pericardial
effusions (Figure 1). Before initiating chemotherapy,
right-sided pleural drainage and pericardial drainage were
necessary. The patient was then started on systemic therapy
according to the BrECADD protocol in accordance with
the German Hodgkin Study Group recommendations for
patients up to 75 years of age. 2
On day 5 of chemotherapy, the patient developed diarrhea
consistent with chemotherapy-induced enteritis. Stool
cultures were negative. Several days later, he experienced
abdominal pain and vomiting. Imaging revealed a
mechanical ileus caused by jejunal stenosis (Figure 2). The
patient had no prior history of abdominal surgery, and
there was no radiological evidence of abdominal lymphoma Figure 1. Positron emission tomography scan showing the large
involvement. Although surgical intervention was indicated, mediastinal tumor mass
it was not performed as it was deemed unfeasible due to
chemotherapy-induced aplasia. Conservative management
with a nasogastric tube, prokinetic agents (neostigmine and
metoclopramide), fluid replacement, parenteral nutrition,
and antibiotic therapy (meropenem) led to resolution of the
ileus over the next several days.
Subsequently, the patient experienced acute GI bleeding
resulting in hemorrhagic shock. The patient had to be
transferred to the intensive care unit for vasopressor support.
Emergency laparoscopy identified a bleeding jejunal ulcer,
requiring segmental small bowel resection. A second
laparotomy with additional jejunal resection was necessary
a few days later due to recurrent bleeding. Histopathological
analysis of the resected jejunal segments revealed severe
ulcerative jejunitis without evidence of lymphoma infiltration.
The patient also developed dialysis-dependent acute
tubular necrosis and transient hyperbilirubinemia. The Figure 2. Computed tomography scan showing high ileus with distention
of the stomach and a jejunal bowel segment
renal failure was attributed to both the cytotoxic effects of
chemotherapy and the neutropenic enteritis. complication. The pathophysiology involves direct cytotoxic
Following a prolonged intensive care unit stay, the effects on enteric neurons and smooth muscle cells, leading
patient was eventually transferred to the general ward. to impaired motility. In addition, chemotherapy-induced
After a brief period of recovery, he unfortunately developed mucosal injury can disrupt the gut barrier, promoting
Candida sepsis, requiring catecholamine support and bacterial translocation and systemic inflammation, which
endotracheal intubation. At the time of manuscript may exacerbate ileus and contribute to sepsis. 3
submission, his outcome remains uncertain. In the event Reports of chemotherapy-induced ileus are quite rare
of sufficient recovery, a de-escalated treatment regimen for in the scientific literature. Published case reports exist for a
his HL is planned, most likely incorporating nivolumab. variety of chemotherapeutic agents and most patients were
3. Discussion successfully managed without surgery. 4-9
BV has been associated with a range of GI complications,
3.1. Chemotherapy-induced ileus
including intestinal obstruction, (neutropenic) enterocolitis,
Chemotherapy-induced (GI) toxicity encompasses a erosion, ulceration, perforation, and hemorrhage, some of
10
spectrum of adverse effects, including nausea, vomiting, which have resulted in patient deaths. A meta-analysis
diarrhea, constipation, and mucositis. Among these, of four lymphoma trials involving over 2,000 patients
bowel obstruction is a rare but potentially life-threatening found an increased incidence of GI adverse events in the

Volume 4 Issue 3 (2025) 106 doi: 10.36922/TD025180033