A 72-year-old woman with a history of long-standing rheumatoid arthritis treated with NSAIDs and under study for chronic diarrhoea of several months' duration by the Digestology Department of another centre. During a diagnostic colonoscopy, the patient suffered an iatrogenic perforation of the descending colon, for which reason she was urgently referred to our centre. With the diagnosis of intestinal perforation, the patient underwent emergency surgery by the General Surgery on-call team, performing a median laparotomy with primary suture of the descending colon. After intraoperative catheterisation of the patient, there was an immediate appearance of frank haematuria, for which reason we were consulted. After initial assessment of the patient and in the absence of other associated symptoms, conservative management was decided and the patient's progress was monitored. In the hours following the operation, the intensity of the haematuria increased and continuous bladder lavage and intravenous treatment with E-aminocaproic acid was started, which did not resolve the symptoms, leading to progressive anaemia that required the transfusion of six units of red blood cell concentrate in the following days. Subsequently, the intensity of the haematuria subsided, although in the two weeks following the operation, it recurred in the form of self-limiting episodes that partially subsided with conservative measures. Six days after the operation, ultrasound was performed, which showed bladder occupation by an image suggestive of a clot, and cystoscopy, which was inconclusive due to intraluminal occupation by a large clot. During the examination, an attempt at lavage was made, which was unsuccessful due to pain, and only the trigonal area could be explored, revealing a filiform clot protruding from the left ureteral meatus. Imaging tests were requested: intravenous urography showed normality of both ureteropielocaliceal systems, which appeared slightly ectatic due to the presence of multiple intravesical repletion defects suggesting the presence of the known clot. The CT scan provided no further information, with similar findings to the previous examination, ruling out pathology of the upper urinary tract.
Given the persistence of the episodes of haematuria and the emission of clots, an examination was scheduled under general anaesthesia, and after profuse lavage with Ellick, the presence of an excrescent lesion with an apparently tumour-like appearance was observed, which was dropping from the cupula along the entire posterior wall, with only the trigonal-peritrigonal area being spared. Given the suspicion of a bladder tumour, extensive transurethral resection was performed, leaving the lesion flat. The anatomo-pathological study of the material submitted showed the presence of amyloid material distributed around the submucosal vessels, as can be seen in the haematoxylin-eosin staining. The eosinophilic character of this material was also revealed by staining with Congo red. Furthermore, immunohistochemical study of the material, with monoclonal antibodies (clone mcl) specific against the AA protein of amyloid, confirmed that the submucosal perivascular deposits corresponded to AA amyloid which stained characteristically by immunoperoxidase reaction. Based on these findings, a diagnosis of secondary bladder amyloidosis was made.
The patient's post-operative evolution was favourable and she was discharged on the 10th day after the operation and subsequently followed up in our outpatient clinic. The patient is currently being followed up for 30 months, with quarterly cystoscopies during the first year and six-monthly during the second year, with no recurrence of the disease to date. Only focal areas of amyloid material in the mucosa were observed in the first cystoscopic controls, which have not generated any subsequent complications.
