Case History
A 41-year-old man with a history of oculodentodigital dysplasia, spastic paraplegia and sacral decubitus ulcers with diverting sigmoid colostomy, chronic back pain on baclofen pump presented with malaise and melena through colostomy. He admitted intermittent use of NSAIDs for chronic back pain. On arrival to ER, he was tachycardic (113/min), with a BP of 126/82 mmHg and pale appearing. His Hgb was 4.9 g/dL (baseline Hgb 12.1 g/dL). CT angiogram of the abdomen/pelvis was negative for active contrast extravasation, however, revealed direct contiguity between the gastric fundus and spleen indicating GSF (figure 1). The patient was resuscitated with IV fluid and required multiple blood transfusions. Splenic artery (SA) angiogram showed hyperemia along the posterior wall of the stomach corresponding to CT findings of GSF (figure 2). Embolization of the main SA, right gastroepiploic, and left omental artery was performed (figure 3). An EGD showed a benign inflammatory mass in the gastric fundus with the invasion of splenic tissue into the gastric mucosa (figure 4). A gastric biopsy was negative for H. pylori and malignancy, however, revealed mild chronic inflammation and reactive gastropathy. Patient was managed with partial gastrectomy and splenectomy. Operative findings were consistent with a large type V gastric ulcer at the fundus with direct extension into the spleen. Pathology of operative specimen demonstrated transmural granulation tissue and acute inflammation with acute serositis and mucosal ulceration without evidence of ischemia. He was discharged to rehab after a prolonged hospital course.