Gastrointestinal Hemorrhage with Splenic Injury

Abstract

Purpose: A 55-year-old man with history of polycystic kidney disease status post renal transplant 1 year ago presented to emergency room with symptomatic anemia and melena for 3 weeks with finding of acute drop in hemoglobin to 6 g/dL. The patient takes aspirin, clopidogrel, and immunosuppressants, including oral corticosteroids. He had endoscopic evaluations 5 weeks prior for chronic anemia, which revealed mild esophagitis, small non-bleeding antral ulcer, diverticulosis, non-bleeding internal hemorrhoids, and small arteriovenous malformations of the ascending colon that were treated with argon plasma coagulation therapy. Physical examination revealed a well-appearing man with stable hemodynamics, benign abdomen with normactive bowel sounds, and melenotic stool in rectum. His laboratory values showed hemoglobin of 6.4 g/dL, INR of 1.2, platelet count of 179/mm3, and ferritin level of 11. His EGD revealed a 5 cm serpiginous vascular-appearing anomaly in the midbody of the stomach with red spots suggestive of recent hemorrhage. This vascular anomaly was noted to bleed spontaneously. There were no visible vessels or mucosal defects. Hemastasis was achieved with epinephrine injection. MRA examination showed venous varix in the posterior gastric wall with vascular supply from splenic vessels. Splenic dysmorphism was noted to be an interval development, with normal spleen seen 5 years ago. The patient later admitted to a fall off the roof of his house resulting in trauma to left thorax and broken left foot three years prior. Splenosis is an acquired condition defined as autotransplantation of viable splenic tissue after traumatic or iatrogenic rupture of the spleen during surgery. It is usually found incidentally in asymptomatic patients and commonly found within the abdominal and pelvic cavities. Splenic tissue show distorted architecture without hilum and poorly formed capsule with blood supply from surrounding vessels. The average time interval between trauma and splenosis formation is 10 years. Splenosis can mimic as malignancies radiographically. Gastrointestinal splenosis has been associated with abdominal pain, mass causing bowel obstruction, and rarely as cause of gastrointestinal or intraperitoneal hemorrhage. Definitive diagnosis of splenosis is made through heat damaged erythrocyte scintigraphy and surgical biopsy. In this case, the etiology of gastrointestinal hemorrhage likely resulted from penetration of splenic implants into the gastric mucosa. Massive hemorrhage from splenosis is rare in reported literature, yet it must be included in the differential diagnosis of patients with gastrointestinal hemorrhage and history of splenectomy or splenic injury.