Lymphoma-Associated Gastrosplenic Fistula
A 60-year-old man with diffuse large B-cell gastric lymphoma involving the spleen and pancreas presented to the emergency department 3 weeks after his first cycle of chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) with complaints of fever, chills, and nausea for the past 2 weeks.
Physical examination. The patient was in no acute distress. His temperature was 37°C, heart rate was of 84 beats/min, and blood pressure was 150/90 mm Hg. He was normocephalic, with equal and reactive pupils. No lymphadenopathy was appreciated. His lungs were clear to auscultation bilaterally. Cardiac examination revealed regular rate and rhythm without murmurs. Abdominal examination revealed no masses and normal bowel sounds; he did have tenderness to deep palpation over the left upper quadrant.
Diagnostic tests. Computed tomography (CT) imaging of the abdomen indicated a possible splenic abscess with air (Figure 1).
Treatment. The patient was admitted to the hospital, and an interventional radiologist placed a CT-guided percutaneous drain into the abscess. Surprisingly, the drain recovered bilious fluid; contrast injected through the drainage tube revealed a large fistulous tract extending from the splenic cavity into the gastric cardia (Figure 2). Further analysis of the fluid revealed vegetable matter and bile but no malignant cells.
Discussion. Diffuse large B-cell lymphoma is the most common type of non-Hodgkin lymphoma. It is aggressive and can occur almost anywhere in the body.1 Common symptoms include fever, weight loss, night sweats, abdominal pain, and, rarely, gastrointestinal tract bleed.1,2
Gastrosplenic fistula is a rare but well-reported manifestation of lymphoma.3-10 Fistulas can develop spontaneously before or after the initiation of chemotherapy. The gastrosplenic ligament serves as the union between these 2 anatomically close organs and as a communication for fistula formation resulting from the growth and spread of tumor cells, tissue necrosis, or infection.1
The primary treatment approach to patients with malignancy-related gastrosplenic fistula has been splenectomy and partial gastrectomy.6,10-12 Nevertheless, resolution of gastrosplenic fistula has been reported with chemotherapy alone.8 Thus, conservative management can be an alternative approach in stable patients with lymphoma-associated gastrosplenic fistula.
Outcome of the case. Our patient’s condition was stable after he underwent drain placement, so conservative management with broad-spectrum antibiotics and dietary restriction (nothing by mouth) was pursued.
Five days later, a radiographic upper gastrointestinal series with radiopaque contrast medium showed an outpouching of the stomach with no fistulous tract (Figure 3). The patient was started on full liquid diet, which he tolerated well. He was released in stable condition, with a percutaneous drainage tube in place, a regimen of oral antibiotics, and a plan for follow-up with his oncologist.
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