Unusual Cause of Upper GI Bleed in a Patient With Lung Cancer

Abstract

Question: A 60-year-old man presented with anemia and black tarry stools, off and on for the last 2 months. He had metastatic non–small-cell lung cancer with metastasis to the liver and spleen. He underwent a left upper lobectomy followed by recent chemotherapy. Physical examination revealed normal vital signs and splenomegaly. Laboratory results showed a drop in hemoglobin from 9.5 to 7.8 g/dL. Esophagogastroduodenoscopy (EGD) revealed a 1.5-cm ulcer in the fundus of the stomach (Figure A). There was no sign of recent bleeding at the ulcer site. Biopsy specimen was taken from the ulcer edges (Figure B). Based on the EGD and pathology, a computed tomography (CT) was performed (Figure C). Based on the image findings, what is your diagnosis and how would you manage the condition? Look on page 288 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. EGD showed a large ulcer in the fundus of the stomach with heaped edges and necrotic base suspicious of malignancy (Figure A). Biopsy from the ulcer (Figure B) showed metastatic squamous cells (arrows) invading into gastric mucosa consistent with metastatic lung cancer. Follow-up CT (Figure C) showed multifocal areas of air within the spleen (arrows) and oral contrast extravasating the stomach into spleen (arrow head) suggestive of a gastrosplenic fistula (GSF). GSF was first described in 1962 by De Scoville et al1De Scoville A. Bovy P. Demeester P. “Aerosplenomegalie” radiologique par lymphocarcome splenique necrosant a double fistulation dans le tube digestif.Acta Gastroenterol Belg. 1967; 30: 841-847Google Scholar as “aero-splenomegaly,” characterized by air in the splenic parenchyma in association with splenomegaly. GSF is an unusual complication of gastric or splenic neoplasms. Cases of GSF associated with splenic abscess,2Ding Y.L. Wang S.Y. Gastrosplenic fistula due to splenic large B-cell lymphoma.J Res Med Sci. 2012; 17: 805-807PubMed Google Scholar Crohn’s disease,2Ding Y.L. Wang S.Y. Gastrosplenic fistula due to splenic large B-cell lymphoma.J Res Med Sci. 2012; 17: 805-807PubMed Google Scholar and trauma3Nikolaidis N. Giouleme O. Gkisakis D. et al.Posttraumatic splenic abscess with gastrosplenic fistula.Gastrointest Endosc. 2005; 61: 771-772Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar have been described. Among the neoplasms, lymphomas are the commonest cause,2Ding Y.L. Wang S.Y. Gastrosplenic fistula due to splenic large B-cell lymphoma.J Res Med Sci. 2012; 17: 805-807PubMed Google Scholar either owing to spontaneous invasion or post chemotherapy regression. To our knowledge, we have described the first case of a GSF associated with lung cancer with metastasis to the spleen. The gastrosplenic ligament facilitates the communication of the 2 anatomically close organs. The fistula forms as a result of tumor growth and spread, tumor necrosis by chemotherapy as in our case, or infection. Bleeding can result from erosion of splenic artery. CT visualization of the fistulous tract or antegrade filling of the splenic cavity by orally administered contrast is diagnostic. Air in the spleen is indicative of GSF, but abscess should be ruled out.2Ding Y.L. Wang S.Y. Gastrosplenic fistula due to splenic large B-cell lymphoma.J Res Med Sci. 2012; 17: 805-807PubMed Google Scholar Gastroscopy may visualize the fistula opening, and may help to establish the diagnosis by tissue sampling as in our case. Treatment of GSF depends on the etiology with surgery being the mainstay of treatment involving splenectomy, partial gastrectomy, and/or distal pancreatectomy.3Nikolaidis N. Giouleme O. Gkisakis D. et al.Posttraumatic splenic abscess with gastrosplenic fistula.Gastrointest Endosc. 2005; 61: 771-772Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Our patient underwent open splenectomy, partial gastrectomy and distal pancreatectomy. He did well postoperatively and his GI bleed resolved. He is being considered for further chemotherapy.