Gastrosplenic fistula due to splenic large B-cell lymphoma
A 62-year-old man was admitted to our hospital (the Second Hospital of Shandong University, Jinan, China) on May 2009 with complaints of left upper quadrant pain that radiated to the back and a history of 8 kg weight loss in the last 2 months in conjunction with fatigue, dyspepsia, and episodic fever in the last 2 weeks. The pain was accompanied by nausea, which worsened to the point where he was unable to lie on his left side. His medical history was negative except appendectomy for acute appendicitis 15 years ago. On the physical examination, there was left upper quadrant tenderness with normal bowel sounds, no peripheral lymphadenopathy or neurological deficit was found, but splenomegaly with a palpable tip was established.\nRoutine admission laboratory tests were as follows: CRP 284 mg/L (normal range, 0–10 mg/L), WBC count 14.6 × 109/L (normal range, 4.0–10.0× 109/L), Hb 92 g/L (normal range, 120–160g/L), and albumin level of 29 g/L (normal range, 30–35g/L). tumor markers were: carcinoembryonic antigen, 2.03 ng/mL (normal range, 0–3.4 ng/mL); a-fetoprotein,3.48 IU/mL (normal range, 0–11.3 IU/ mL); and CA19-9,13.44 U/mL (normal range, 0–39 U/mL). The chest and abdominal radiographs showed no abnormality. Abdominal CT scan showed the presence of air in the spleen, and a 1.6 cm fistulous tract between the stomach and the hilum of an enlarged spleen, with a large splenic abscess []. Esophagogastroduodenoscopy showed next to the cardia in the greater curvature of the stomach an ulcerative lesions with regular margins (about 3 cm wide, 7 cm deep) and the rest of the gastric mucosa without alterations. Cold forceps biopsy specimens of the ulcer and splenic tissue were obtained, which on immunohistochemistry showed large tumor cells with vesicular nuclei and prominent nucleoli; the cells stained positive for CD20, suggesting diffuse large B-cell lymphoma. Bone-marrow biopsy or flow cytometry did not reveal any other evidence of disease.\nLaparotomy was performed after the patient's albumin level improved to 38 g/L and correction of his anemia. Under general anesthesia, the abdomen was opened via a 18 cm-long midline incision. On exploration, the spleen was found to be densely adherent to the diaphragm, lateral abdominal wall, and greater curvature of the stomach by an abscess. The adhesions were separated with digital palpation. Following the dissection of the spleen, an inflamed and necrotic 7 cm of splenic segment and approximately 2 cm of fully perforated fundus were found leading to the GSF. The patient underwent splenectomy, gastric wedge resection of the greater curvature, and distal pancreatectomy. The GSF was confirmed in the gross specimen. The pathological report of spleen surgically removed was large B-cell lymphoma, consistent with endoscopical biopsy. Postoperatively, the patient received intensive care for 3 days and was able to resume a full diet on day 4. Recovery was uneventful. Adjuvant chemoradiotherapy was started on the 16th postoperative, day and the patient remained well at follow-up.