P1004 - A Rare Case of Gastrosplenic Fistula in Diffuse Large B-cell Lymphoma

Michelle Shah, DO¹, Kelsey Collins, MD¹, Gres Karim, MD¹, Samuel Daniel, MD^2
1Mount Sinai Beth Israel Medical Center, New York, NY; ²Mount Sinai St. Luke's and Mount Sinai Roosevelt, New York, NY

Introduction: Gastrosplenic fistula (GSF) is a rare complication that can occur in various diseases, but most commonly is secondary to lymphoma. We present a case of an elderly female who was found to have splenic abscess with fistulization to the stomach, and a gastric mass consistent with diffuse large B-cell lymphoma (DLBCL).

Case Description/Methods: A 69 year old female presented to the hospital with worsening epigastric pain and dizziness for two weeks, associated with bloating sensation, intermittent chills, early satiety and a five pound weight loss in the past month. Labs were notable for white blood cell count 15.9 K/uL and hemoglobin 6.8 g/dL, and CT of the abdomen and pelvis (CTAP) revealed an 8.6 x 6.4 cm splenic abscess that broadly abutted the stomach consistent with unclear communication. EGD revealed a 5 cm gastric tumor with a fistulous connection within the mass along the anterior wall of the cardia. Tissue biopsy of the gastric mass revealed large B-cell lymphoma, and tumor cells were positive for CD20, mum-1, and bcl-6. Cell proliferation marker MIB-1 was > 90%, and immunohistochemistry revealed lymphoma cells focal positive for c-myc with cytogenetic studies pending to assess for double-hit. She underwent image-guided splenic abscess drainage, however repeat CTAP showed fistulous communication between the splenic abscess and the gastric cardia and two necrotic perigastric lymph nodes suspicious for metastatic lymphadenopathy. Steroids and R-CHOP were started inpatient given high risk of upper gastrointestinal bleed and viscus perforation with rapid tumor shrinkage, and she was planned for complete gastrectomy with roux-en-y reconstruction and complete splenectomy.

Discussion: DLBCL typically presents with nodal enlargement in the neck, abdomen or mediastinum, but may present as a mass anywhere in the body. GSF is a rare and potentially fatal complication of lymphoma, and on literature review only case reports exist describing gastrosplenic fistulas. A systematic review of all 27 existing case reports was conducted analyzing features of GSF in lymphomas. GSF most commonly occurred in DLBCL, splenic abscess was diagnosed in three cases, and partial gastrectomy was performed for surgical resection in most patients. Given the large tumor extent, our patient was planned for complete gastrectomy and splenectomy. Further research is needed to fully characterize morbidity and mortality based on severity of clinical features, size of tumor burden, and type of intervention chosen.


Figure: A) Fistulous communication with the cardia of the stomach
B) Fluid and air-containing collection within the spleen


Disclosures:
Michelle Shah indicated no relevant financial relationships.
Kelsey Collins indicated no relevant financial relationships.
Gres Karim indicated no relevant financial relationships.
Samuel Daniel indicated no relevant financial relationships.


Michelle Shah, DO¹, Kelsey Collins, MD¹, Gres Karim, MD¹, Samuel Daniel, MD². P1004 - A Rare Case of Gastrosplenic Fistula in Diffuse Large B-cell Lymphoma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.