10 The lesions in the stomach, like the esophagus, can be categorized into hemorrhagic, infiltrative, agranulocytic, and fungal2 and may even mimic gastric carcinoma.11 Leukemic infiltration of the stomach may appear as nodules,

thickened folds,12,13 or ulcers.14 Leukemic processes are similar in the small and large bowel.2 In general, they increase in frequency from the duodenum to the terminal ileum, and are mainly hemorrhagic and infiltrative in type. Infiltration of the small bowel may result in prominent mucosal folds, a protein-losing LDE225 datasheet enteropathy,15 and impaired D-xylose absorption.16 A review of colonoscopies in leukemia shows that most lesions are aphthoid and small ulcers due to leukemic infiltration.17 Also reported are reddish, ubiquitin-Proteasome system flat or slightly elevated lesions, nodular lesions, and polypoid masses.12,18,19 The last two may cause intussusception, bowel obstruction, or simulate colonic carcinoma.2,20 The appearance of leukemic infiltrates may suggest ulcerative colitis, ileocolitis, or proctitis,2 and may respond to chlorambucil.21 Other GI complications of leukemia include perforation, pneumatosis cystoides intestinalis, and pneumoperitoneum.22 Painful anorectal lesions found in leukemia include

thrombosed hemorrhoids, ulceration, fistulas, abscess formation, stercoral ulcers, and necrosis.23–25 Surgery is indicated for the release of collections of pus2,23,25 although formation of pus may be reduced in a tender infected area due to marked leukopenia. Patients with acute or chronic leukemia may present with cholecystitis-like symptoms and gallbladder wall infiltration.26,27 Pancreatitis is rare although leukemic infiltration of the pancreas at autopsy is common.28 Pancreatitis may be due to L-asparaginase,

even 10 weeks after stopping therapy.29 Infiltration of lymphoreticular organs, mainly spleen, liver, and lymph nodes, occurs in many patients with leukemia and is more prominent in chronic than acute disease.4 Splenic size is greatest with CML, intermediate with CLL, Clomifene and least with acute leukemias. Rupture of the spleen has been described with no history of trauma to the abdomen30 and is more common in acute than in chronic leukemia.31 Several mechanisms have been incriminated: (i) leukemic infiltration of the spleen especially if the capsule is invaded; (ii) splenic infarction followed by subcapsular hemorrhage; and (iii) defects in blood coagulation, particularly thrombocytopenia.31,32 Splenic rupture occurs in the context of splenomegaly (in 70% of patients) with nearly all complaining of abdominal pain, sometimes referred to the left shoulder.33 Splenic infarcts occur in 16% of patients who die of leukemia; these infarcts occur more commonly in those with CML than in acute leukemia.