Gastric hemorrhage due to splenomegaly following repair of a type A aortic dissection

Abstract

A 44-year-old hypertensive male was admitted with a type A aortic dissection originating just above the aortic valve and involving the innominate, left subclavian, left renal, and bilateral iliac arteries. The celiac, superior mesenteric, and splenic arteries were not involved in the dissection. An echocardiogram revealed an aortic root diameter of 4.7 cm with moderate aortic insufficiency due to aortic valve prolapse. At the time of surgery, cardiopulmonary bypass was established with right axillary artery and right atrial cannulation. The aortic root and ascending aorta were replaced with a #25 Carbomedics composite conduit (Sorin Group Italia S.R.L., Milan, Italy). The aortic specimen showed no evidence of any connective tissue disease. During the postoperative period, the patient developed acute renal failure which required institution of continuous renal replacement therapy. On the 10th postoperative day, the patient became hypotensive and developed midepigastric pain, hematemesis, and bloody stools. His hematocrit decreased from 12.2 to 4.5 g/dL and his international normalized ratio was 2.3. Coumadin was discontinued and vitamin K and fresh frozen plasma were administered. He continued to have hematemesis and gastroscopy showed active bleeding from a 3.5 × 4.0 cm mass in the posterior wall of the gastric fundus (Figure 1). An abdominal computed tomography scan showed no gastric mass, but instead, revealed an enlarged spleen (135.47 × 43.49 × 110 mm 3 postop vs 98.38 × 33.92 × 93.50 mm 3 preop), with the upper pole compressing the posterior wall of the gastric fundus creating a mass-like effect (Figure 2). These findings were confirmed at the time of laparotomy and a splenectomy and partial gastrectomy was performed. FIGURE 1The gastroscopy showed the mass was at the posterior wall of the fundus, 3.5 cm × 4 cm. There was extravasated blood surrounding the mass J Card Surg. 2018;33:853-854.wileyonlinelibrary.com/journal/jocsThe pathology showed no evidence of any gastric tumor or splenic emboli or ischemic changes other than congestion. The splenic artery had no evidence of dissection. The patient tolerated the procedure well and was subsequently discharged on coumadin without any further hematemesis.