When organs collide: A rare cause of gastrointestinal bleeding.

A 72-year-old man was referred to our Emergency Department with a 2-week history of melaena. His medical history was relevant for Atrial Fibrillation and Non-Hodgkin's Lymphoma (NHL) in remission on most recent PET. Our patient responded to resuscitative management and then went on to have upper gastrointestinal endoscopic evaluation to elucidate the cause of bleeding. As seen in the images, endoscopy showed a gross defect in fundal wall with evidence of extrinsic infiltration by a large vascular mass-like structure, suspected to be spleen. Computed tomography (CT) abdomen and pelvis confirmed a gastrosplenic fistula as well as new lymphadenopathy. The findings were in keeping with recurrence of NHL. Discussion at multidisciplinary meeting deemed his gastrosplenic fistula unsuitable for surgical repair. He was managed conservatively, had a nasojejunal (NJ) tube inserted for feeding, and clinically improved on the ward. Our patient expressed a preference not to undergo further chemotherapy, having struggled quite significantly with his initial chemotherapy. He was discharged home 23 days following admission. At this stage, his NJ tube was removed and he was tolerating oral diet. He is currently being managed by the Palliative Care team in the community.

Medically managed coronary artery aneurysm without concomitant stenosis.

Coronary artery aneurysms (CAAs) are relatively rare with an incidence varying from 1.4% to 5.3% of patients undergoing coronary angiography. Studies suggest that management of CAA can be guided by the absence or presence of significant coronary artery stenosis, with most concluding that CAA associated with stenosis of ≥70% should be managed surgically or with percutaneous intervention. However, given the paucity of cases described in the literature and lack of randomised control trials, no consensus exists on the natural history, prognosis or management of CAAs without significant concomitant stenosis. We present a case of medically managed atherosclerotic CAA without significant stenosis that was found to no longer be present on coronary angiography performed 11 years after initial diagnosis.