S2961 Splenic Infarction Leading to Gastrosplenic Fistula in COVID-19

Abstract

INTRODUCTION: Gastrosplenic fistulas are rare with no reported cases resulting from acute infarction. Coagulopathy is commonly reported in COVID-19 infection. We present a first instance of gastrosplenic fistula as sequalae of celiac artery plexus thrombosis resulting in splenic infarction in setting of COVID-19 infection. CASE DESCRIPTION/METHODS: A 51 year-old female with chronic gastritis & no personal or family history of thrombosis, treated for COVID-19 pneumonia 1 month prior, presented 2 weeks after discharge with epigastric pain, coffee ground emesis & fever. CT with angiography showed thrombosis of celiac trunk, common hepatic, splenic & left gastric arteries, fistulation of gastric wall & splenic fossa with gastric contents in spleen, splenic abscess & complete splenic infarction. Small bowel follow-through showed contrast in spleen. EGD visualized a large gastric fistula. No specimen was collected as surgical repair was planned. Labs showed positive SAR-CoV2 RNA, negative H. pylori stool antigen, stable hemoglobin 8-9.5g/dL, thrombocytosis of 703K/µL, fibrinogen 397mg/dL, heterozygous Factor V Leiden mutation, & no antithrombin 3 deficiency, protein S deficiency, or JAK2 mutation. She remained on antibiotics, IV heparin & PPI with no further signs of GI bleed. More conservative approach was favored & a percutaneous drain was placed into splenic abscess with cultures growing 2 strains of ESBL E. coli & Candida glabrata. Patient remained stable, tolerated diet & was discharged on long term antibiotics & anticoagulation. DISCUSSION: Gastrosplenic fistulas are rare & caused by gastric or splenic pathologies causing erosion & fistulation due to proximity. Literature review shows no reported cases of splenic infarction as cause of gastrosplenic fistula. We hypothesize COVID-19 related coagulopathy & underlying Factor V Leiden heterozygosity led to arterial thrombosis & complete splenic infarction as mechanism of fistulation. While gastric lymphomas & ulcers are reported causes, EGD 3 months prior showed unremarkable biopsies throughout & EGD during hospitalization showed no gastritis or other lesions. Splenic abscesses are reported in literature as cause of gastrosplenic fistulas. While no imaging timeline is established to rule out abscess as mechanism of fistulation, they are also rare & caused most commonly by hematologic seeding. With negative blood cultures, no other source of infection & triple organism abscess culture, it is more likely fistulation occurred with seeding of spleen through fistula.Figure 1.: Axial view of the upper abdomen. A gastrosplenic fistula is noted. There is a wall defect along the greater curvature of the stomach with gastric contents and air entering a fistulous tract that extends posterolaterally to the spleen.Figure 2.: EGD visualization of non-bleeding gastric fistula in wall of gastric body.Figure 3.: Radiograph of the upper abdomen five minutes after administration of oral contrast. Oral contrast is present within the stomach and the proximal duodenum. There is abnormal contrast in the left upper quadrant of the abdomen overlying the spleen.