Colosplenic contained perforation secondary to colonic lymphoma.

We present the case of patient with colosplenic perforation from a colonic lymphoma. He initially was diagnosed with a splenic abscess subsequently developed a contained colonic perforation, underwent surgical treatment and intraoperatively was diagnosed with lymphoma. This is a rare entity in a non-immunocompromised host and has been scarcely reported.

CASE REPORT

The patient is a 56-year-old male, who presented to our facility with complaints of left upper quadrant abdominal pain. His past medical and surgical history was significant for diverticulosis, appendectomy and pilonidal cyst resection. One month prior to his presentation, the patient experienced mild diffuse abdominal pain but denied weight loss or night sweats. His family physician started him on a course of antibiotics for suspected diverticulitis, which improved his symptoms. After 2 weeks, his symptoms returned and a computed tomography (CT) scan of the abdomen showed a possible splenic hematoma as described by the outlying hospital radiologist and he was prescribed a new course of antibiotics. Of note is that the patient was not on any anticoagulation therapy nor had any recent trauma. His symptoms continued thus his representation.

On arrival the patient had moderate left upper quadrant tenderness without peritonitis and mild leukocytosis. A repeat CT showed a 7.6 cm splenic abscess with extravasation contrast from the adjacent colon [Figure 1]. Based on these findings the patient was started on intravenous antibiotics and a CT-guided drain was placed in the abscess cavity, subsequently, being discharged home on broad-spectrum oral antibiotics. His drain contents became enteric, consistent with a moderate output fistula. Over the next several weeks, he continued to have moderate output from the drain and worsening abdominal pain. Since this continued to be a moderate output fistula it was decided to proceed with resection.

Figure 1

CT abdomen and pelvis show a 7.6 cm by 5.5 cm fluid collection noted in the inferolateral aspect of the spleen, which contains multiple gas bubbles, and is consistent with an abscess. There is a small curvilinear focus of hyperattenuation in the inferior spleen that represents extravasated contrast from the adjacent splenic flexure of the colon

Approximately 8 weeks after his initial presentation, the patient underwent a laparoscopic left hemicolectomy and splenectomy converted to open due to inflammatory process involving the spleen, distal pancreas and colonic. We performed a left hemicolectomy, splenectomy and distal pancreatectomy to remove this mass en bloc. The patient's postoperative course was uncomplicated.

Pathology results showed a 10 cm diffuse large B-cell lymphoma of colon with colonic perforation and infiltration into the spleen and pancreas. One of 19 regional lymph nodes was positive. Postoperative additional staging studies including a CT scan of his chest, positron emission tomography (PET) scan, which did not show any associated lesions. Patient was seen again in our office following discharge and he was recovering appropriately.

DISCUSSION

Primary gastrointestinal lymphoma accounts for 30-40% of all extranodal lymphomas. Colonic lymphoma is less common in comparison to the stomach or small bowel.[1]

Many studies have documented colonic lymphoma's propensity for forming fistulas. Fistulas most commonly involved the urinary bladder, vaginal cuff, other loops of bowel and rarely to other organs.[234]

Goldberg et al.,[2] and Naschitz et al.,[5] present cases of colosplenic fistula from lymphoma. In these cases authors suggested that ulceration and extensive coagulative necrosis of a bulky large cell lymphoma are the prerequisites for fistula formation. The case presented, differs in terms of the fact that there was no colonic mass visible through the imaging studies nor was the patient diagnosed before this presentation with lymphoma.

CONCLUSIONs

We report an unusual case of colosplenic contained perforation caused by a primary gastrointestinal B-cell lymphoma originating from the colon in a previously healthy non- immunocompromised patient.