A rare case of splenic lymphoma in a patient with polymyositis manifesting as gastric variceal bleeding

Abstract

We report an unusual case of upper gastrointestinal bleeding due to isolated gastric variceal bleeding in a patient with splenomegaly who was subsequently diagnosed with diffuse large B-cell lymphoma. The patient is a 47-year-old male with a history of polymyositis who presented to the emergency room with complaints of lightheadedness and melena for 2 days. On initial presentation, the patient had positive orthostatic vital signs. He was found to be anemic with presenting hemoglobin of 5.8 g/dl (compared with 13.4 g/dl 4 months prior to presentation). The patient was aggressively resuscitated with intravenous fluid and blood transfusions. An emergency esophagogastroduodenoscopy was performed which showed isolated gastric varices in the fundus of the stomach, with no active bleeding or high-risk stigmata. Abdominal computed tomography revealed focal splenic vein thrombosis and splenomegaly with ill-defined hypodensities. Portal and superior mesenteric veins were patent. Mild edema was seen surrounding the spleen and non-specific abdominal lymphadenopathy was also reported. A surgical consultation recommended an urgent splenectomy. Pathology of the removed spleen revealed diffuse large B-cell lymphoma. Positron emission tomography-computed tomography revealed lymphomatous disease in the thorax, abdomen, pelvis and bone marrow. The patient was subsequently started on chemotherapy.

Isolated Gastric Fundal Varices Caused by Diffuse Large B-Cell Lymphoma

“…To our knowledge, we have only found 5 case reports published in peer-reviewed journals of lymphoma causing UGIB through IGV. 4,[10][11][12][13] Our patient was managed conservatively with a nonselective b-blocker, vasoactive agent, and proton pump inhibitor. The decision to manage our patient conservatively was multidisciplinary in nature, with active communication between the medical oncology, gastroenterology, and internal medicine teams.…”

A Rare Case of Gastric Variceal Hemorrhage Secondary to Infiltrative B-Cell Lymphoma

“…Surgical removal of the spleen decreases venous outflow through collateral circulations and decompresses IGV to prevent future bleeding [8]. To the best of our knowledge, there have only been two other published case reports of large B-cell lymphoma causing upper GI bleeding from IGV [9,10]. These cases were treated with splenectomy or chemotherapy alone.…”

“…These risks include infection with encapsulated organisms, intra- and postoperative hemorrhage, thrombocytosis, pancreatitis, and gastric fistula formation, with reported morbidities and mortalities ranging from 8 to 52% and from 0 to 9%, respectively [11, 12]. One previous case report suggested that surgery might have been avoided in at least one case if the diagnosis of lymphoma had been considered preoperatively [9]. This illustrates the importance of recognizing the etiology of LSPH and considering less invasive management strategies when possible.…”