A rare case of air in the Spleen reported

Dr Simon De Freitas, at Johns Hopkins Hospital and Health System, Baltimore, MD and colleagues have reported a rare case of air in the Spleen. The case has appeared in the New England Journal of Medicine.

A gastrosplenic fistula (GSF) is an unusual complication arising from a variety of primary gastric or splenic malignant lesions and less commonly from benign diseases. Gastrosplenic fistula is very rare (28 cases have been described during the last 27 years) and a potentially fatal complication of various diseases, including lymphoma, gastric adenocarcinoma, Crohn's disease, splenic abscess, and trauma. The first gastrosplenic fistula (GSF) was reported in Belgium in 1962. The authors described a case of the gastrosplenic fistula with a characteristic radiographic appearance due to the presence of air in the spleen, which they termed “aerosplenomegaly”.Perforated gastric ulcers have variable presentations. Most cases present with extraluminal air, pancreatitis, or lesser sac abscess. Other unusual cases may be associated with pneumopericardium, subcutaneous emphysema, splenic abscess, tension pneumothorax, gastropleural fistula, gastrobronchial fistula, gastropancreatic fistula, gastroenteral fistula, and penetration into the heart and aorta.

A 56-year-old woman presented to the emergency department with a 1-month history of epigastric and left-upper-quadrant abdominal pain. Her medical history included polysubstance use disorder (including cocaine and heroin use) and hepatitis C virus infection, as well as rheumatoid arthritis, for which she had been taking naproxen.

Courtesy NEJM

On the day after admission to the hospital, the patient had acute worsening of the abdominal pain. She had new abdominal tenderness on physical examination, including involuntary guarding and rebound tenderness. Computed tomography of the abdomen revealed extensive air in the spleen, as well as intraperitoneal free air. The patient underwent exploratory laparotomy, during which an ulcer measuring 2 cm in diameter was identified on the greater curvature of the stomach, with fistulization into the spleen. A splenectomy and gastric wedge resection were performed. Histologic examination confirmed a diagnosis of peptic ulcer disease. On follow-up 10 weeks later, the patient had recovered from the surgery and had no abdominal pain.

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nejm.org/doi/full/10.1056/NEJMicm1817266