Volume 85 - 2022 - Fasc.4 - Case series
Endoscopic diagnosis of a colonic localisation of a mantle cell lymphoma
Extra-nodal localisations of mantle cell lymphomas are most frequently found in the gastrointestinal tract. It is therefore important for an endoscopist to be familiar with the endoscopic image of a mantle cell lymphoma. In this case series of three patients with colonic involvement of mantle cell lymphoma, we discuss the endoscopic diagnosis. (Acta gastroenterol. belg., 2022, 85, 632-634).
Keywords: colonoscopy, gastrointestinal lymphoma, polypoid lesions. Introduction
Hematological malignancies such as lymphomas can present throughout the entire gastrointestinal tract (1, 2). As a matter of fact, one of the most frequent extra-nodal presentations of mantle cell lymphomas particularly, is in this gastro-intestinal tract (3,4). The typical image on colonoscopy is that of a lymphoid polyposis. These polyps are most frequently visible in the ascending colon, followed by the ileum, stomach and duodenum. In the stomach not only polyposis-like images are encountered, but also gastritis and ulcerative lesions are seen with mantle cell lymphoma. The image of polyposis in the colon, should be differentiated from adenomatous polyposis and benign lymphoid hyperplasia (4-6).
Less than 10% of all non-Hodgkin lymphomas are mantle cell lymphomas. They are B-cell lymphomas which vary significantly from asymptomatic to very aggressive tumours (7). The median age at presentation is approximately 60 years and there is a 2:1 ratio for men (3,7,8). Despite the heterogeneity regarding the aggressiveness, few patients survive without an allogenic stem cell transplant (7,8) although the life expectancy can still be many years.
Splenic injury during colonoscopy: modern treatment approach and splenic salvage
Splenic injury is a rare complication of colonoscopy, estimated to occur in 0.020 to 0.034% of procedures, with a 30-day mortality of 3.6% (1-3). Of the three major severe adverse events during colonoscopy (perforation, bleeding, and splenic injury), splenic injury has the highest mortality but is rarest (1). The spleen is attached to the colonic splenic flexure by the splenocolic ligament, suggesting that manipulation of the colon during colonoscopy may cause direct tension or impaction on the spleen and splenic hilum as the mechanism of injury (2,3). Patients typically present within 24 hours of colonoscopy with severe abdominal pain and peritonism, and may be haemodynamically unstable (2).
The majority of published cases of high-grade splenic injury due to colonoscopy have been managed with splenectomy (2,3), however smaller numbers have been managed with embolization and conservative measures (3). Modern treatment options for splenic injury due to colonoscopy can be classified into con- servative, endovascular, and surgical management (3). Conservative management involves inpatient moni- toring, with analgesia, intravenous fluids, and blood transfusion (2,3). Endovascular treatment is splenic artery embolization, typically with deployment of coils into the splenic artery proximal to the splenic hilum or into a single splenic artery branch in cases with an isolated focal injury (2-4). Surgical management is principally laparotomic splenectomy (2,3). In modern treatment protocols, splenectomy is usually reserved for unstable patients who require emergent laparotomy (4). Given the similarity in mechanism between splenic injuries due to blunt trauma and those due to colonoscopy, it may be helpful to conceptualize splenic injuries due to colonoscopy according to the American Association for the Surgery of Trauma (AAST) grading system (5).
After institutional ethical approval, electronic medical records over a 10-year period (2012-2022) were searched to identify all patients treated for splenic injury due to colonoscopy, with the following inclusion criteria:
• Splenic laceration diagnosed on computed tomography (CT).
Colonoscopy within 72 hours of CT diagnosis.
• Absence of blunt external traumatic incident between
colonoscopy and diagnosis.