Endoscopic Closure of a Gastrosplenic Fistula (GSF) in a Patient with Diffuse Large B-Cell Lymphoma (DLBCL)

Abstract

Gastrosplenic fistula (GSF) is a rare complication arising from malignant and less commonly benign diseases involving the stomach or spleen. Lymphoma is the most commonly associated malignancy resulting in formation of GSF. We report a unique case of GSF secondary to diffuse large B cell lymphoma (DLBCL) managed by endoscopic closure. Case Report: A 67-year-old male with rheumatoid arthritis was admitted for failure to thrive, reporting 40 lb unintentional weight loss, poor appetite, and fatigue over 3 months. He also complained of abdominal pain with oral intake. His history was negative for alcohol, tobacco, illicit drugs, and family history of malignancy. On physical exam the patient was remarkable for cachexia and a palpable tender mass in the left upper quadrant. Initial bloodwork was notable for a white blood cell count of 16.7 K/mcL, hemoglobin of 11.8 g/dL, platelets of 313 K/mcL, albumin of 2.3 g/dL. Computed tomography (CT) scan of the abdomen revealed an enlarged spleen with a 10.4 cm gas and fluid-filled, cavitary lesion and several smaller hypodensities consistent with aerosplenomegally (Image 1). CT guided fine needle aspiration was notable for foul smelling brown fluid which was submitted for gram stain, culture, and cytopathology. Subsequently a Jackson-Pratt drain was placed. Cytopathology confirmed the presence of vegetable matter (Image 3). An upper GI series and subsequent CT abdomen confirmed a GSF (Image 2). The patient was made NPO and started on total parenteral nutrition. Diagnostic upper endoscopy revealed a 9 mm clean based ulcer with irregular borders, and heaped edges 6 cm below the gastroesophageal junction on the posterior wall of the fundus. (Image 4,5). Given the amenable size of the ulcer, a 9 mm Over-The-Scope-Clip (OTSC) was deployed with closure of the defect (Image 6,7). Post procedure 1 L of methylene blue was administered orally with no dye seen in the JP drain. Repeat CT confirmed closure of the GSF. Pathology from the ulcer biopsy was consistent with DLBCL.Figure 1Figure 2Conclusion: Currently, 15 cases of GSF associated with lymphoma have been reported. Management included conservative therapy, surgical resection, chemotherapy or both when deemed feasible. This is the first ever reported case of endoscopic closure of a GSF associated with a DLBCL. Closure of the fistula was significant as it allowed the reintroduction of oral feeds to optimize the patients' nutritional status which was essential for further treatment.