Editorial - Journal of Gastroenterology and Digestive Diseases (2021) Volume 6, Issue 11
Gastro-splenic fistula an uncommon show of sickle cell infection patient with splenic canker.Susanna Larsson*
Faculty of Medicine, Department of Gastroenterology and Digestive Diseases, Valparaiso University, Valparaiso, USA
- *Corresponding Author:
- Susanna Larsson
Faculty of Medicine
Department of Gastroenterology and Digestive Diseases
E-mail: [email protected]
Accepted on November 03, 2021
Hemoglobinopathies such as thalassemia and sickle cell disease are risk factors for splenic abscess formation. Gastrosplenic fistula is a rare complication of splenic abscess. In the literature, there are no reported cases of gastro-splenic fistula in patients with hemoglobinopathies. We are presenting a rare case of a 15-year-old boy with undiagnosed sickle cell trait with splenic sequestration crisis as first presentation of his disease. This was complicated by splenic abscess formation. Gastro- Splenic fistula was not apparent in computed tomography and upper gastrointestinal endoscopy findings were misinterpreted initially, which lead to delay in diagnosis and management. The patient was managed initially with antibiotics, followed by splenectomy and partial gastrectomy. Gastro-splenic fistula is not a common entity. It may be caused by gastric or splenic pathologies. In our case, which is the first reported in literature, the fistula developed as a complication of splenic abscess in patient with sickle cell disease. Its presentation depends on the underlying condition. CT scan is the modality of choice for diagnosis. Upper GI endoscopy findings of the fistula is often misinterpreted. The treatment of fistula is splenectomy and partial gastrectomy. Hemoglobinopathies such as thalassemia and sickle cell disease are prevalent in the eastern region of Saudi Arabia with sickle cell trait accounting for up to 17% of the population. Herein, we present a very rare complication of sickle cell trait in which a patient developed a splenic abscess eroding the stomach. This work has been reported in line with the SCARE criteria.
A previously well 15-year-old boy presented with sudden onset of left-sided abdominal pain and symptoms of anemia. His physical examination was remarkable for massive splenomegaly and his laboratory investigations were significant for low hemoglobin level (7 g/dl). Hemoglobin S level of 45% and Hemoglobin F level of 15% by HPLC (High-Performance Liquid Chromatography) confirming the diagnosis of Sickle Cell Trait. The patient denied any previous complaints or hospital admissions related to sickle cell disease. He was admitted to the Intensive Care Unit (ICU) in another hospital where he received blood transfusion and referred to our hospital for further management. Three weeks later upon presentation to our hospital, he was febrile, pale and jaundiced. Abdominal examination revealed left hypochondriac tenderness and massive splenomegaly. A Computed Tomography (CT) Scan of the abdomen showed massive splenomegaly with splenic infarction and possible superimposed infection. The plan for further management was taken after the discussion in a multi-disciplinary team consisting of hematologist, surgeons, gastroenterologist, intensivist and infectious disease consultant. The patient was started on hydration, proper analgesia and antibiotics with a plan for operation after his condition improves. Prior to surgery, he had an episode of vomiting which was thought to be coffee-ground. Vomitus; accordingly, upper GI endoscopy was done and the edematous gastric mucosa in the fundus was misinterpreted as large gastric varices at the time of the study. Patient underwent. Endless supply of writing, we observed just three instances of gastro-splenic fistula because of splenic boil, not a single one of them with hematological illness. In the biggest series of splenectomies in sickle cell infection patients in our space, just 7 out of 173 seen with splenic boil and required a medical procedure however not a single one of them had gastric fistula.
The standard administration of gastro-splenic fistula is a medical procedure, in type of splenectomy and fractional gastrectomy as for our situation. Different types of the board incorporate stapling the elaborate piece of the stomach or separating the fistula lot and over sewing the stomach. Laparoscopic approach can be used, yet in instances of huge splenomegaly, open methodology is liked. There are accounted for instances of moderate administration as boil desire however it is prudent to go with careful administration to keep away from huge or repeat of GI dying. Open splenectomy under general anesthesia after being prepared with hydration, analgesia, simple blood transfusion and incentive spirometry to prevent perioperative complications. During the operation, multiple infarcts and abscesses were seen. The spleen was fused to the stomach. Upon dissection of the adhesions, a fistulous tract was found connecting the stomach fundus to the spleen with copious amount of pus coming out. The fistula was managed by partial gastrectomy. Three days post-operative, contrast meal study was done which demonstrated no leak at the surgical site.
Patients with hemoglobinopathies, especially sickle cell illness typically present with gentle splenomegaly during the primary decade of life, which then, at that point, goes through moderate decay prompting autosplenectomy due to rehashed assaults of vaso-impediment and dead tissue. Nonetheless, splenic intricacies in patients with sickle cell infection are not exceptionally unprecedented and patients can give fluctuating levels of splenomegaly. These incorporate a range of problems like splenic localized necrosis, hypersplenism, intense splenic sequestration emergency and splenic sore, which can be muddled by fistula arrangement.
Splenic boil as such in patients with sickle cell infection is viewed as extremely uncommon with commonness around 0.7% in dissection studies. The finding can be postponed or missed in these patients as the show can be at first ascribed to vaso-occlusive emergency and splenic dead tissue. Gastro-splenic fistula is a remarkable element and is normally brought about by numerous basic conditions. The pathogenic system includes moderate invasion, disintegration and entrance of the stomach divider. Due to the closeness between the gastric fundus and the spleen a fistulous lot can be framed. This can happen with either gastric or splenic pathologies. For gastric pathologies, this component can clarify the announced instances of gastro-splenic fistula brought about by dangerous conditions like lymphoma and gastric adenocarcinoma, notwithstanding harmless conditions like gastric ulcers and Crohn's illness. For splenic pathologies, causes incorporate splenic lymphoma and splenic canker, which can be inclined by haemoglobinopathies like sickle cell sickness/quality, injury or sepsis.
In instances of gastro-splenic fistula, normally the show is of the fundamental condition, not for the actual fistula. Patients normally present with stomach agony, delicacy and fever. Splenomegaly is just seen as in portion of the cases. Upper GI draining is an uncommon show yet can prompt genuine outcomes. CT check is the methodology of decision for the conclusion of gastro-splenic fistula. Upper GI endoscopy can envision the fistula opening but since of the uncommonness of the condition and in light of edematous mucosa, discoveries may be misconstrued as varices or ulcers (as for our situation). Ultrasound can just picture splenic assortments.
In our patient, we are detailing the first gastro-splenic fistula in splenic sore happening after sequestration emergency in a sickle cell quality patient as first show of his sickness. We accept that our patient could be quick to be accounted for portraying gastrosplenic fistula in a sickle cell characteristic with splenic boil because of sequestration emergency as first show of the infection anti-infection agents expanded extensively after some time during the review time frame. E. faecium has been accounted for to be more impervious to anti-microbials than non-faecium enterococci, in light of proof of usually utilized anti-microbials, including ampicillin-sulbactam, being ineffectual against E. faecium. Thusly, vancomycin is suggested for contaminations with E. faecium. The principal identification of VREFM in this review was from tests acquired during the later years (2013- 2017) of the researched period, and practically these patients had grade II intense cholecystitis (94.7%). Consequently, different anti-toxins, including linezolid and tigecycline, which give great inclusion against VREFM, ought to be considered for patients with such progressed contaminations. Albeit one report noticed the helpless viability of tigecycline for seriously sick patients with septic shock, tigecycline can be utilized in a few different cases due to its expansive range of adequacy against gramnegative microorganisms, including ESBL-creating microscopic organisms. As enterococci have only sometimes been related with bacteremia, it is as yet questionable to manage antimicrobials when enterococci are detached from culture tests. Be that as it may, antimicrobial treatment ought to be emphatically considered for high-hazard patients like immunocompromised patients with nosocomial diseases, seriously sick patients with a background marked by taking expansive range anti-toxins, and patients at high danger of endocarditis.