A fistula between the stomach and spleen is a very rare clinical manifestation. Aetiologies include gastric adenocarcinomas,1
benign gastric ulcers3
Gastric and splenic lymphomas can also fistulate with other organs, including the bronchus19
Extensive splenic necrosis and gastric wall infiltration is required for gastrosplenic fistula formation.9
It can occur after chemotherapy as a result of rapid regression of the tumour that has infiltrated the gastric mucosa thus resulting in a fistula.4 6 12 13
Alternatively, as in our case, it can occur spontaneously. The aggressive nature of diffuse large B cell lymphomas and the tendency for adjacent organ invasion contributes to this spontaneous fistula formation.9 11
These features were seen in our case where there was extensive infiltration of adjacent organs, including the pancreas and diaphragm.
To our knowledge, there have been only six reported cases of spontaneous gastrosplenic fistula associated with a primary splenic lymphoma.5 7–9 16
We report the seventh case of a spontaneous gastrosplenic fistula from a primary splenic non-Hodgkin's lymphoma.
The clinical presentation of diffuse large cell splenic lymphoma usually consists of left upper quadrant abdominal pain accompanied by features of a systemic illness and splenomegaly on examination.5
These characteristics were also present in our patient. Furthermore, our patient's admission was complicated with haematemesis, which has been the clinical presentation of other gastrosplenic fistulas.6 8
Multislice CT provides the best imaging modality to identify gastrosplenic fistulas10 14
due to excellent spatial resolution and accurate staging of lesions. The clinical presentation of our patient coupled with the absence of any significant past medical history or evidence of endocarditis helped to exclude other differential diagnoses such as necrotising splenic abscess. In previously described cases the spleen was shown to be heterogenous with parenchymal masses containing air, similar to our case.8 9
The fistulous tract has been outlined with oral contrast7
in some cases. One other case of gastrosplenic fistula in the literature was identified by a retrograde catheter cystography for a suspected splenic abscess that inadvertently revealed itself as a fistula.13
Radical surgical resection is the most common treatment option, which would typically demand a splenectomy and gastrectomy. However, there are reports of necessary distal pancreatectomies performed in some cases.14
Although open procedures are more commonly described, there has been a successful laparoscopic case.17
An advantage of surgical resection is that it aids in establishing a pathological diagnosis in uncertain cases.11
In contrast, there are also cases of resolution of the fistula with chemotherapy.3 18
Patients are at risk of haematemesis due to the risk of invasion into adjacent vasculature, specifically the gastric and splenic vessels. Treatment can also be supportive and in life threatening blood loss interventional radiology in the form of splenic artery embolisation8
has been described. Surgery in our patient would have been a huge undertaking with associated high mortality in view of the size of the lesion and multiple adjacent structures involved. The patient was not clinically septic and chemotherapy was therefore the treatment option offered. The presence of fistulas, risk of haemorrhage and infection highlights the challenges faced with managing tumoural fistulas.
- A gastrosplenic fistula is a rare complication of lymphoma.
- It can occur spontaneously or after chemotherapy.
- Multislice CT with intravenous and oral contrast demonstrated the site of pathology, complications such as varices, the fistula tract and any invasion of adjacent organs.
- Treatment modalities include surgical resection, chemotherapy or a combination of both.