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Primary oesophageal lymphoma is an exceptionally rare cancer originating in the esophagus, distinct from more common oesophageal malignancies. Dawson's criteria has been the mainstay for diagnosis for such entities. However, recognizing primary oesophageal lymphoma is particularly challenging due to its rarity, diverse clinical presentations, and non-specific radiological and endoscopic features. These factors often lead to diagnostic delays, complicating timely treatment and resulting in poor patient outcomes. We hereby present a challenging case and literature review about this rare malignancy. A 78-year-old male was referred to Gastroenterology for evaluation of dysphagia. Initial esophagogastroduodenoscopy (OGD) revealed an oesophageal ulcer with features consistent with oesophageal candidiasis. A follow-up OGD identified an oesophageal stricture. Histopathology and immunohistochemistry of biopsy samples confirmed a diagnosis of diffuse large B-cell lymphoma (DLBCL). A staging CT was completed, and an oesophageal mass was shown extending into the mediastinum. The patient re-presented with worsening dysphagia, renal dysfunction, and hypercalcemia. Although lymphoma was confirmed, to ensure an appropriate regimen is commenced, a repeat OGD was recommended by the Hematology team. The patient's rapid deterioration necessitated pre-phase steroid treatment and management of tumor lysis syndrome. Before R-CHOP chemotherapy could begin, the patient deteriorated further. Following a multidisciplinary team (MDT) meeting and discussions with the patient and family, it was decided to manage the symptoms with palliative intent. This case highlights the diagnostic challenges posed by primary oesophageal lymphoma, emphasizing the importance of considering this rare malignancy in the differential diagnosis of oesophageal strictures, particularly in elderly patients. Aggressive disease progression complicates managing DLBCL in older patients. Moreover, this patient population has other co-morbidities that would preclude treatment options at the outset. Further studies are needed to establish optimal diagnostic and therapeutic strategies for this rare condition., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Sidana et al.)

Plasmablastic lymphoma (PBL) is an uncommon and aggressive type of mature B cell lymphoma rarely involving gastrointestinal (GI) tract. Here, we describe a case of PBL involving the colon in HIV/Epstein-Barr virus negative immunocompetent patient who presented with anaemia and weight loss but no significant GI symptoms. It emphasises that even in the absence of classical risk factors, one should consider possibility of this condition as this is potentially curable. Also, we would like to highlight the diagnostic and treatment challenges of such an aggressive lymphoma in a frail elderly patient with multiple comorbidities., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate the diagnostic utility of single-operator peroral cholangioscopy (SOC) in patients with sclerosing cholangitis., Methods: All patients with sclerosing cholangitis who underwent SOC procedures due to suspicious biliary strictures, in one Swedish and four UK tertiary centers in 2008-2012, were retrospectively enrolled. For each SOC procedure in sclerosing cholangitis, another one attempted due to a single biliary stricture in the same center and calendar year was randomly selected as control. Patients were followed up until death or last clinic visit until November 2012., Results: Fifty-four SOC procedures were attempted in 52 sclerosing cholangitis patients (48 with primary sclerosing cholangitis, 4 with IgG4-related sclerosing cholangitis). Cannulation with the SOC system failed more frequently in sclerosing cholangitis (15% vs. 2% in controls; p = 0.015). The sensitivity, specificity, and accuracy of SOC (including tissue sampling) for cancer diagnosis were similar in sclerosing cholangitis and controls (50% vs. 55%, 100% vs. 97%, and 88% vs. 80%, respectively) with largely overlapping confidence intervals. Adverse events were more common in sclerosing cholangitis, due to an increased frequency of cholangitis (11% vs. 2% in controls; p = 0.051)., Conclusions: SOC is equally accurate in cancer diagnosis in sclerosing cholangitis and patients with single biliary strictures. However, cholangioscope insertion may be hampered by bile duct narrowing and post-SOC cholangitis is more common in sclerosing cholangitis.

Background and Aim: We aimed to evaluate the diagnostic utility of single-operator peroral cholangioscopy (SOC) for indeterminate biliary lesions and its usefulness in electrohydraulic lithotripsy (EHL) of biliary stones not amenable to conventional endoscopic therapy., Patients and Methods: All patients undergoing SpyGlass SOC in four UK tertiary centres between 2008 and 2010 were retrospectively enrolled. Patients were followed up until death or the last clinic visit until May 2011. The operating characteristics of SOC for detecting malignant lesions and the stone clearance rate after SOC-guided EHL were calculated., Results: A total of 165 patients underwent 179 SOC procedures. Sixty-six percent were referred for indeterminate biliary strictures, 13% for filling defects and 21% for SOC-guided EHL. Cannulation with the SOC system was successful in 95% but visualization was inadequate in 13%. Primary sclerosing cholangitis was a risk factor for failed cannulation and conscious sedation (vs. general anaesthesia) for inadequate visualization (P<0.05). The accuracy of SOC for diagnosing malignant lesions was 87%. SOC-guided biopsies were adequate in 72%. Obtaining at least four versus less than four biopsy specimens resulted more often in adequate samples (90 vs. 64%, P=0.037). Complete stone clearance could be achieved in 73% of patients. The adverse event rate was 9.6%. Cholangitis was the most common event (56%, one fatal)., Conclusion: SOC is useful for the differential diagnosis of indeterminate biliary lesions and the treatment of 'difficult' biliary stones. The adequacy of SOC-guided biopsies is related to the number of specimens obtained. Primary sclerosing cholangitis is related to failed cannulation with the SOC system, whereas general anaesthesia is related to adequate visualization.