A 72-year-old female patient with a history of long-standing rheumatoid arthritis treated with NSAIDs and in a study of chronic diarrhea for several months of evolution by the Digestology Service of another center.
As a diagnostic challenge, the patient suffers an iatrogenic perforation of the descending colon, which is why she is urgently referred to our center.
With the diagnosis of intestinal perforation, the patient underwent emergency surgery by the General Surgery Department, performing a midline laparotomy with primary suture of the descending colon.
After the intraoperative catheterization of the patient, there is an immediate appearance of frank hematuria, reason why we consult.
Initially evaluated the patient and in the absence of other associated symptoms was decided conservative management and see evolution.
In the hours after the intervention, the intensity of hematuria was increased, introducing continuous bladder lavage and intravenous treatment with E-aminocaproic, which did not resolve the condition resulting in a progressive transfusion.
Subsequently, the intensity of hematuria subsided, although within two weeks after the intervention, it was repeated as self-limiting episodes that partially resolved with conservative measures.
Six days after surgery, an ultrasound showed occupation by an image suggesting clotting and cystoscopy, which was inconclusive due to the intraoral occupation of a large clot.
During the exploration, a washout attempt was made which was unsuccessful due to pain, and it was only possible to explore the area of the anal cavity, observing a clot-forming wheat that was abolished by the left ureteral meatus.
The following imaging tests were requested: intravenous urography, which showed the normality of both systems known as localised clots, which appeared slightly ectatic due to the presence of multiple bladder filling defects.
The CT did not provide further information, with findings similar to the previous examination, ruling out pathology of the upper urinary tract.
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wheat persistence of hematuria and clots emission was programmed under general anesthesia, appreciating after profuse wash with Ellick, the presence of an excrecent lesion and apparently tumoral scolgon
Suspicion of bladder tumor was made extensive transurethral resection leaving the lesion flat.
Pathological examination of the material revealed the presence of amyloid material distributed around the submucosal vessels, as can be seen in hematoxylin-eosin staining.
The eosinophilic character of this material was also demonstrated by congo red staining.
On the other hand, the immunohistochemical study of the material, with specific monoclonal antibodies (mcl clone) against the amyloid AA protein, confirmed that the amyloid perivascular deposits were characteristic of cutaneous AA.
All these findings led to the diagnosis of secondary bladder amyloidosis.
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The postoperative evolution of the patient was favorable, being discharged on the 10th day after the intervention and subsequently followed in our external consultations.
Currently the patient is followed up for 30 months, performing quarterly cystoscopy during the first year, and every six months during the second, with no recurrence of the disease so far.
Only focal areas of amyloid material in the mucosa that have not generated any subsequent complication were observed in the first cystoscopic controls.
