An 88-year-old female presented with dyspnea on exertion and severe anemia. Colonoscopy was unremarkable and the patient was transfused with packed red blood cells prior to discharge. The patient returned 2 weeks later with severe abdominal pain, hypotension, and anemia. Computed tomography revealed splenic hematoma and hemoperitoneum. She bled from the surgical sites during emergent splenectomy and work-up revealed hemophilia A. We present, to our knowledge, a case of the longest reported delay in presentation of post-colonoscopy splenic rupture and the first in a patient with hemophilia A.

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Morgagni hernias are congenital diaphragmatic disruptions that occur when intra-abdominal organs herniate posterior to the sternum. It is very rare to concomitantly diagnose a paraesophageal hernia (PEH) in a patient with a Morgagni hernia. Here, we describe an elderly female patient presenting with severe chest pain subsequently diagnosed with a non-strangulated Morgagni hernia as well as PEH. She underwent successful robotic laparoscopic surgical repair of the hernias with resolution of her symptoms. This case demonstrates the need for early surgical intervention of Morgagni hernias to prevent sequelae, such as strangulation, and the rising benefits of laparoscopic repairs in adult patients.

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approach. An enlarged lymph node was identified in peripancreatic region measuring 24.2 mm by 10.9 mm, an additional fine needle biopsy was obtained. Pathology of pancreatic mass and lymph node later revealed fragments of lymphoid tissue consistent with reactive lymph node with single cluster of cytologically mildly atypical cells however no evidence of metastatic malignancy was appreciated. Immunohistochemical staining was positive for CD3 and CD20. CD56, chromogranin, synaptophysin, CD10, e-cadherin and AMACR stains were negative. Flow cytometry analysis was ordered. It demonstrated no evidence of a lymphoproliferative disorder. A three-month post procedure MRI was obtained which demonstrated a 1.6 cm nodule at neck of the pancreas increased in size when compared to prior image. (Figure ) Discussion: In immunology, TLS are a highly debated topic as to whether they serve as mediators of protective or pathologic immune responses in certain chronic inflammatory diseases and in the regulation of immune responses. When associated with both primary and or metastatic tumors they're known as tumor-associated TLS (TA-TLS). In cancer their presence is associated with prolonged increased rates of disease-free survival. When identified flow cytometry should always be ordered in order to rule out a lymphoproliferative disorder. TLS and its implications are still an area of active study, clear guidelines in terms of management are still being developed. Furthermore as to whether they represent premalignant lesion is still unknown. Our patient remains asymptomatic and continues to be monitored with serial imaging.[1842] Figure 1. A. Magnification 200x. Small fragment of benign pancreatic acinar cells near lymphoid cluster. B. Magnification 100x. Aggregates of lymphoid tissue with intervening capillaries representing lymph node like structure within pancreas. C. MRI Abdomen with contrast showing 1.3 cm enhancing nodule at neck of pancreas. D. EUS. Fine needle aspiration of 11.4 mm by 8.5 mm intrapancreatic mass.