Spontaneous gastrosplenic fistula in primary gastric lymphoma: Surgical management

Gastrosplenic fistula due to splenic lymphoma: two case reports and review of the literature

BACKGROUND

Gastrosplenic fistula is a rare and potentially fatal complication of various conditions. Lymphoma is the most common cause. It can occur spontaneously or after chemotherapy. Gastrosplenic fistula diagnosis can be confused with a splenic abscess because of the presence of air into the mass. The computed tomography identification of the fistulous tract is the key to a right diagnosis. Treatment modalities include surgical resection, chemotherapy, or a combination of both.

CASE PRESENTATION

Here we report two patients with gastrosplenic fistula due to diffuse large B cell lymphoma. The first patient was a 54-year-old Caucasian woman with an enormous primary splenic diffuse large B cell lymphoma leading to the development of a spontaneous fistula in the stomach. The second patient was a 48-year-old Caucasian male patient with an enormous splenic diffuse large B cell lymphoma complicated by fistula after chemotherapy. Both patients died of septic shock several days after surgery.

CONCLUSION

Gastrosplenic fistula is a rare complication with a poor-prognosis, for which surgery is currently the preferred treatment.

A Retrospective Cohort Study of Gastrosplenic Fistula Secondary to Malignant Etiology: Single-Centre Experience of 5 Cases

Gastrosplenic fistula is an uncommon manifestation of malignancy of the stomach and spleen. The aim of this study is to present our 10-year experience on gastrosplenic fistula secondary to malignant etiology. Endoscopy, imaging, and histopathology records of all the patients with gastric and splenic malignant pathologies were reviewed retrospectively. The protocol was approved by the ethical review board of the institute. Descriptive statistics were used to summarize the data. A total of 5 cases were found to have gastrosplenic fistula. Of these 5 cases, 2 were due to large B cell lymphoma of the spleen, 1 was secondary to Hodgkin's lymphoma of the stomach, 1 case was due to diffuse large B cell non-Hodgkin's lymphoma of the stomach, and 1 patient was secondary to gastric adenocarcinoma. Gastrosplenic fistula is an exceptionally rare complication of gastrointestinal malignancy. Lymphoma of the spleen is the commonest cause while gastric adenocarcinoma causing gastrosplenic fistula is extremely rare. Most cases occur spontaneously.

Gastrosplenic Fistula: a Systematic Review

Gastrosplenic fistula is an unusual complication of benign as well as malignant gastric and splenic pathologies. This pathology acquires an important clinical significance due to its rare association with life-threatening upper gastrointestinal haemorrhage. The aim of this article is to review the English-language literature in order to gain a better understanding of etiological factors, diagnostic evaluation, and management of gastrosplenic fistula. The systematic search of the literature was performed on PubMed and MEDLINE from January 1950 to September 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. We retrieved 44 articles matching our selection criteria from the search. There were 3 case series, 37 case reports, and 4 review of the literature. In our appraisal of articles published in PUBMED, a total of 36 cases of malignant and 10 cases of benign gastrosplenic fistula could be identified. Gastrosplenic fistula is an exceptional complication of malignancies of the gastrointestinal tract. Lymphomas particularly arising from the spleen are the commonest cause. Gastric adenocarcinoma causing GSF is extremely rare. Most cases occur spontaneously, but at times, it can be secondary to tumour necrosis following chemotherapy.

Complications of lymphoma in the abdomen and pelvis: clinical and imaging review

Involvement of the abdomen and pelvis is common in lymphoma. Nodal and extranodal abdominal and pelvic lymphoma may present with various complications. Complications are most common in high-grade lymphomas, especially diffuse large B-cell lymphoma. Complications may occur as the initial manifestation of lymphoma, during treatment course, or late following complete disease remission. Most complications are associated with worse prognosis and increased mortality. Imaging is essential in evaluation of disease extent and diagnosis of complications. Therefore, radiologists should be familiar with the clinical context and imaging features of abdominal and pelvic lymphoma complications. We provide a comprehensive, organ system-based approach, and clinical and imaging review of complications of abdominal and pelvic lymphoma along with radiologic images of illustrated cases of the most commonly encountered complications.

Gastro-Splenic Fistula Related to Large B Cell Lymphoma

We report a case of spontaneous gastrosplenic fistula in a 57 year old female who presented to the emergency department with abdominal pain and weight loss. From the physical examination, she had a palpable abdominal mass. A CT scan was performed and showed a mass involving the proximal greater curve of the stomach, infiltrating the spleen and pancreas. There was a 12 mm defect in the cardia of the stomach with gas entering the large mass but there was no free gas in the abdomen. The defect was a gastrosplenic fistula. A gastroscopic biopsy confirmed the diagnosis of diffuse large B cell lymphoma. Surgical removal of the mass was not feasible; therefore she was treated with RCHOP chemotherapy, achieving complete remission.

Gastrosplenic Fistula without Malignancy Management in a 16-Year-Old Boy

Gastrosplenic fistula is a very rare entity, most commonly occurring as a distinctive complication of splenic or gastric malignancies, most notably diffuse large B cell lymphoma (DLBCL). Benign gastric ulcer, splenic abscess, and Crohn's disease have also been reported as possible causes. We report a nonmalignant case of 16-year–old male with a gastrosplenic fistula of unclear etiology. The fistulous tract was confirmed by an upper endoscopy and an upper gastrointestinal series. Subsequently, it was surgically managed with a subtotal gastrectomy with “Roux-en-Y” reconstruction and a feeding jejunostomy.

Lymphoma Causing Gastrosplenic Fistula Revealed by FDG PET/CT

A 73-year-old man presented with fatigue and weight loss. He had CT-proven splenic mass with fistulous connection to the greater curvature of the stomach, which suggested abscess. FDG PET/CT confirmed gastrosplenic fistula in addition to active lymph nodes in the gastrohepatic ligament and epigastric region. Pathological examination after the biopsy of the spleen was consistent with diffuse large B-cell lymphoma. Chemotherapy was administered with close clinical follow-up and resulted in the resolution of fistula without requirement for surgery.

Gastrosplenic fistula occurring in lymphoma patients: Systematic review with a new case of extranodal NK/T-cell lymphoma

AIM

To provide the overall spectrum of gastrosplenic fistula (GSF) occurring in lymphomas through a systematic review including a patient at our hospital.

METHODS

A comprehensive literature search was performed in the MEDLINE database to identify studies of GSF occurring in lymphomas. A computerized search of our institutional database was also performed. In all cases, we analyzed the clinicopathologic/radiologic features, treatment and outcome of GSF occurring in lymphomas.

RESULTS

A literature search identified 25 relevant studies with 26 patients. Our institutional data search added 1 patient. Systematic review of the total 27 cases revealed that GSF occurred mainly in diffuse, large B-cell lymphoma (n = 23), but also in diffuse, histiocytic lymphoma (n = 1), Hodgkin’s lymphoma (n = 2), and NK/T-cell lymphoma (n = 1, our patient). The common clinical presentations are constitutional symptoms (n = 20) and abdominal pain (n = 17), although acute gastrointestinal bleeding (n = 6) and infection symptoms due to splenic abscess (n = 3) are also noted. In all patients, computed tomography scanning was very helpful for diagnosing GSF and for evaluating the lymphoma extent. GSF could occur either post-chemotherapy (n = 10) or spontaneously (n = 17). Surgical resection has been the most common treatment. Once patients have recovered from the acute illness status after undergoing surgery, their long-term outcome has been favorable.

CONCLUSION

This systematic review provides an overview of GSF occurring in lymphomas, and will be helpful in making physicians aware of this rare disease entity.

Massive gastrointestinal bleeding after chemotherapy for gastric lymphoma

INTRODUCTION

Gastrosplenic fistula (GSF) is a rare condition almost always associated with lymphoma, with gastric and splenic involvement.

CASE REPORT

We report a 52 year old male with gastric lymphoma admitted to the emergency department with hematemesis. The first chemotherapy cycle had been completed four weeks before. Oesophagoduodenoscopy showed a pulsatile ulcerated lesion. Surgical hemostasis was performed. Four days after surgery, the patient initiated sudden and massive upper gastrointestinal bleeding with hemodynamic compromise. A gastrosplenic fistula was recognized during emergency laparotomy and an en bloc total gastrectomy and splenopancreatectomy resection was performed, with massive blood transfusion. Patient was discharged 13 days after the second surgery.

DISCUSSION

Gastrosplenic fistula is a rare condition, previously described associated with gastric lymphoma at presentation or after treatment. A prompt recognition of the underlying pathology could avoid a second surgery.

CONCLUSION

A systematic and interdisciplinary approach is the key for success in rare challenging emergencies. Infrequent etiologies must always be considered as they need specific therapeutic approaches that defy paradigms.

Uncommon acquired fistulae involving the digestive system: summary of data

PURPOSE

Most gastrointestinal fistulae commonly occur following surgery. A minority is caused by a myriad of other etiologies and is termed by some as "uncommon fistulae". The aim of this study was to review these fistulae and their treatment.

METHODS

A literature review was carried out. Searches were conducted in Pubmed and related references reviewed.

RESULTS

Except for Crohn's disease and diverticulitis, "uncommon fistulae" are described in case reports or very small case series. Most of the patients were treated by surgery.

CONCLUSIONS

The anatomic features of the fistula and the etiology usually dictate the approach. Most patients will eventually need surgery to resolve this pathology.

Spontaneous gastrosplenic fistula secondary to primary splenic lymphoma

A gastrosplenic fistula is a rare complication of gastric and splenic lymphomas which can occur spontaneously or secondary to chemotherapy. We report a case of a spontaneous gastrosplenic fistula secondary to a diffuse splenic large B cell lymphoma in a previously well 43-year-old patient. CT imaging demonstrated the fistula, which was subsequently managed with chemotherapy. The clinical management of this rare condition is discussed with a review of the literature.

Spontaneous gastrosplenic fistula secondary to primary splenic lymphoma

A gastrosplenic fistula is a rare complication of gastric and splenic lymphomas which can occur spontaneously or secondary to chemotherapy. We report a case of a spontaneous gastrosplenic fistula secondary to a diffuse splenic large B cell lymphoma in a previously well 43-year-old patient. CT imaging demonstrated the fistula, which was subsequently managed with chemotherapy. The clinical management of this rare condition is discussed with a review of the literature.