P1234 - Intestinal Nodular Lymphoid Hyperplasia Diagnosis and Practice Management: A Systematic Review and Treatment Algorithm for Quality Improvement

Sunday, October 22, 2023

3:30 PM – 7:00 PM PT

Location: Exhibit Hall

Presenting Author(s)

ES

Elizabeth F. Sun, BS (she/her/hers)

Vanderbilt University School of Medicine
Nashville, Tennessee

Elizabeth F. Sun, BS¹, Tian Zhang, BS¹, Rishi D. Naik, MD, MSCI²
¹Vanderbilt University School of Medicine, Nashville, TN; ²Vanderbilt University Medical Center, Nashville, TN

Introduction: Intestinal nodular lymphoid hyperplasia (NLH) is an endoscopic finding with inconsistent long-term follow-up, inadequate guidelines, and high variability in practice management. While the pathogenesis of intestinal NLH is unclear, NLH has been associated with several pathogenic states including immunodeficiency, malignancy, and infections. There are no formal guidelines for the management, diagnostics, nor follow-up on NLH. This systematic review aims to 1) investigate the incidence of conditions associated with NLH and 2) improve practice management for the further evaluation of nodular lymphoid hyperplasia.

Methods: We searched PubMed, Cochrane Library, and ClinicalTrials.gov databases as well as the abstracts from relevant national scientific meetings. A systematic review from the year 1985 onward on the topic of intestinal nodular lymphoid hyperplasia (NLH) was performed. Study type, median/mean age, and associated diseases were recorded. Pediatric populations were excluded. Based on our findings, a management diagram on recommended testing upon finding of NLH was devised.

Results: Initial literature search yielded 25 manuscripts [2 retrospective reviews (n=83), 1 cohort (n=40), and 22 case reports (n=28)]. Median age of diagnosis was 42 years old. Of the 151 patients, when a systemic disease was present, the most common were H. pylori (27.8%), Immunodeficiency (17.2%), Malignancy (9.9%), and Giardia (5.3%) (Table 1). In 25.2% of patients, no etiology was identified. Given the variability seen in this retrospective review, a diagnostic algorithm was then created to mirror this epidemiological data (Figure 1).

Discussion: Practice management is variable for a diagnosis of NLH due to lack of adequate guidelines. This study is the largest analysis assessing the systemic cause of NLH performed to date. Our findings support that further evaluation and testing should be performed when a pathological diagnosis of NLH is made. H. pylori had the highest rate of discovery followed by an immunodeficiency. Given that many of these conditions are not diagnosed on small bowel biopsies, further non-invasive testing is recommended for process improvement to reduce post-procedure variability.

Figure: Figure 1: Treatment Algorithm for Nodular Lymphoid Hyperplasia

Study	Year	Method	Number of Patients	Median age of NLH dx (years)	Immunodeficiency	Malignancy	Giardiasis	H. pylori	No Associated dx
Matuchansky et al.	1985	Case Report	5	26		3	4
Aguilar et al.	1987	Case Report	1	55	1	1
Bastlein et al.	1988	Case Report	1	31	1
Harris et al.	1989	Case Report	3	37	1	3
Castellano et al.	1992	Case Report	1	39	1	1
Yamaue et al.	1996	Case Report	1	63					1
Samman et al.	2000	Letter to Editor	1	26	1
Tomita et al.	2002	Case Report	1	62
Rubio-Tapia et al.	2006	Retrospective Review	18	41	9	3	1
Perez-Roldan et al.	2008	Case Report	1	59			1
Molaei et al.	2009	Case Report	1	31	1
Mee Joo et al.	2009	Case Report	1	32	1
Khuroo	2011	Cohort Study	40	35.6				40
Monsanto et al.	2012	Case Report	1	62		1
Garg et al.	2012	Case Report	1	60	1
Basyigit et al.	2014	Case Report	1	34	1			1
Said-Criado et al.	2014	Clinical Picture	1	32	1
Olmez et al.	2014	Case Report	1	38	1		1
Ouakaa-Kchaou et al.	2015	Case Report	1	24	1
Bansal et al.	2016	Case Report	1	59	1
Hanich et al.	2017	Case Report	1	38	1	1
Lin et al.	2017	Retrospective Review	65	31.9 (mean)	1	2		1	36
Choi et al.	2017	Case Report	1	41	1		1
Morais et al.	2018	Case Report	1	41	1
Pellegrini et al.	2022	Case Report	1	39					1
		TOTAL	151	41.5 (mean)	26	15	8	42	38

Table: Table 1: Conditions Most Commonly Associated with Nodular Lymphoid Hyperplasia

Disclosures:

Elizabeth Sun indicated no relevant financial relationships.

Tian Zhang indicated no relevant financial relationships.

Rishi Naik indicated no relevant financial relationships.

Elizabeth F. Sun, BS¹, Tian Zhang, BS¹, Rishi D. Naik, MD, MSCI². P1234 - Intestinal Nodular Lymphoid Hyperplasia Diagnosis and Practice Management: A Systematic Review and Treatment Algorithm for Quality Improvement, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.