Scope It Out Case Answers 
Fall 2026

Answer: Diffuse large B-cell lymphoma (DLBCL).

Explanation:

Mantle cell lymphomas: typically expresses CD20, CD5, cyclin D1, and SOX11. This case had negative CD5.

Small Bowel adenocarcinoma: B-cell immunophenotype argues against this diagnosis.

Small bowel Crohn’s disease: a discrete large jejunal mass containing atypical B lymphocytes would be atypical.

 

Discussion and Teaching Points

Small bowel malignancies are uncommon, and lymphoma represents an important subset. Small bowel lymphoma may present with nonspecific symptoms, including abdominal pain, weight loss, anemia, or occult GI bleeding. Mucosal ulceration and tumor friability can lead to chronic blood loss even in the absence of overt bleeding. Some of the predisposing conditions include: autoimmune diseases (eg, celiac disease); immunodeficiency syndromes; long-standing immunosuppressive therapy; Crohn disease; radiation therapy; nodular lymphoid hyperplasia; and infectious disease (eg, EBV).

Thiopurines are associated with ~2-3 fold increased risk of lymphoma and DLBCL is the most common subtype, often EBV-positive and resembling post transplant lymphoproliferative disorder (PTLD). Thiopurines impair immune surveillance of EBV infected B cells, cause DNA damage and deplete NK cells with IFN-γ deficiency.

This case highlights the complementary roles of capsule endoscopy and device-assisted enteroscopy in evaluating suspected small bowel bleeding after negative conventional endoscopy. Capsule endoscopy helped identify the suspected lesion, while double-balloon enteroscopy enabled direct visualization, tissue acquisition, and tattoo placement for subsequent localization.

Clinical Pearl: In patients with unexplained iron-deficiency anemia or suspected occult GI bleeding and negative EGD and colonoscopy, small bowel evaluation is essential. Ulcerated masses identified during enteroscopy should prompt biopsy to exclude malignancy, including lymphoma.

 

​​​Summer 2026

 

Answer: B

This is a case of diffuse large B-cell lymphoma. Patient underwent R-CHOP chemotherapy. After 2 months, he is doing much better, tolerating a regular diet with no nausea or vomiting.

Spring 2026

The most likely cause is: 
C. Autoimmune Hepatitis 

Why? 

This patient has several classic features of autoimmune hepatitis (AIH): 

• Marked hepatocellular injury with very high AST/ALT 

• Positive ANA 

• Liver biopsy showing interface hepatitis with plasma cell infiltrate — this is highly characteristic of AIH 

• Initial improvement followed by relapse/worsening after discharge, which is common in untreated autoimmune hepatitis 

Although he initially reported taking an online “men’s vitality supplement,” which raises concern for drug-induced liver injury (DILI), some drugs/supplements can actually trigger autoimmune hepatitis or an AIH-like syndrome. The biopsy findings strongly favor true autoimmune hepatitis. 

Why not the others? 

• A. Drug induced liver injury 

  • Supplements commonly cause DILI, but classic histology for DILI is variable. 

  • The presence of interface hepatitis with plasma cells and positive ANA strongly points toward AIH. 

  • The relapse despite stopping the supplement also argues against a simple toxic DILI. 

• B. Alcohol associated hepatitis 

  • Typically AST and ALT are much lower (<500), with AST:ALT ratio >2. 

  • Plasma cell/interface hepatitis pattern is not typical. 

• D. Hepatic lymphoma 

  • Would not classically present with this biopsy pattern or marked transaminase elevation. 

Winter 2026

Part 1:

2) Titrate spironolactone up to 400 mg/day and furosemide up to 160 mg/day.

Part 2:

(3) refer to TIPS

 

​​Fall 2025

B. Both FDA and EASL recommend withholding terlipressin and decreasing albumin if there is hypoxemia (SpO2<90%) or evidence of volume overload or ischemia, regardless of renal response due to the risk of respiratory and cardiac complications. 

 

Summer 2025

​B. LES Botulinum toxin injection

Botox is the best option even though it may only provide short-term relief. Patient is not a candidate for Heller myotomy because severe comorbidities. Pneumatic dilation is not a reasonable option due to risk of perforation which would require surgery to correct. POEM would not be considered a safer alternative to Heller myotomy or pneumatic dilation. Sildenafil is not a treatment for type II achalasia and heart failure would be a contraindication. Nitrates and calcium channel blockers are less effective.