Augusta University Medical College of Georgia Augusta, GA
Introduction: Gastric ulcer is commonly caused by NSAIDs use or H pylori infection. Direct invasion of extraluminal tumor is considered a rare cause. Here, we report a case of bleeding gastric ulcer caused by invasion of recurrent large B cell lymphoma (DLBCL) in splenic bed post splenectomy.
Case Description/Methods: A 75-year-old woman with diffuse large B cell lymphoma (DLBCL) status post splenectomy one year ago, currently receiving chimeric antigen receptor T cell chemotherapy (Tisagenlecleucel) presented with hematemesis and syncope. Of note, recurrent lymphoma adjacent to the gastric greater curvature was noted in the splenic bed on the follow-up positron emission tomography-computed tomography a few weeks ago (Figure).
Physical examination was significant for tachycardia, hypotension, and mild epigastric tenderness to palpation.
Laboratory data revealed a white blood cell of 3,600/mm3 (reference range: 4,500-11,000/mm3), hemoglobin of 6.5 g/dL (reference range: 12-16 g/dL), and platelet of 58,000/mm3 (reference range: 150,000-400,000/mm3).
The patient received intravenous proton pump inhibitor drip and packed red blood cell transfusion. Esophagogastroduodenoscopy (EGD) was performed urgently after adequate resuscitation, which revealed a large amount of blood clots in the stomach and an actively bleeding large ulcer (5x5 cm) in the gastric fundus (Figure). Hemospray was applied to achieve hemostasis. Given the concern of rebleeding, the patient was referred to interventional radiology for Gelfoam embolization of the left gastric artery. A follow up Abdominal CT showed a 8.8 x 8.1 cm mass communicating with the lumen of the stomach along the greater curvature, consistent with fistula formation. No further gastrointestinal bleeding was reported after procedures.
Discussion: This case highlights a rare cause of a gastric ulcer, which was caused by a recurrent diffuse large B cell lymphoma in the splenic bed. Primary splenic DLBCL causing a gastric bleeding ulcer as a gastro-splenic fistula has been reported previously; however, our patient had a splenectomy with recurrence of the splenic DLBCL in the abdominal cavity. The recurrent lymphoma adjacent to the gastric greater curvature was noted in the splenic bed causing fistula formation. Given the aggressive nature of DLBCL, fistula formation between the spleen and stomach plays an important role in gastric bleeding. Although a splenectomy was performed, a fistula was noted between the recurrent tumor and the greater curvature of the gastric body.
