Spontaneous rupture of a normal spleen

Abstract

A 55-year-old lady with no significant past medical history presented to A&E with an hours history of sudden onset of left hypochondrial and epigastric pain, radiating to her left shoulder. She was a moderate smoker, did not abuse alcohol or drugs, did not suffer from indigestion and was not on any medication. She was alert with a Glasgow Coma Score of 15, apyrexial, heart rate of 75 regular beats per minute, blood pressure was 120/80 mmHg and had a respiratory rate of 18 min � 1 . She was not distressed. Her abdomen was tender over the epigastrium and left upper quadrant, with no guarding or rebound. The rest of her abdomen was soft and non-tender. Her bowel sounds were diminished. On arrival her haemoglobin was 13.7 g, a white cell count of 7:1 � 10 9 l � 1 , a normal biochemistry and serum amylase. ECG and erect chest X-ray were normal. The supine abdominal film showed normal psoas shadows. She was kept under close observation. (An urgent ultrasound scan of the abdomen was requested, but could not be done in time.) Later her systolic blood pressure dropped to 90 mmHg with accompanying tachycardia and sweating. She was resuscitated with crystalloid, and had an emergency laparotomy. She was found to have a large haemopeitoneum consisting of fresh and clotted blood. The spleen could be easily mobilised, there were no adhesions, and was found to be in two pieces. The spleen is normally attached to the greater curvature of the stomach and the left kidney by the gastro-splenic and lienorenal ligaments. The splenic vessels that enter at the hilum, passes between the layers of the lienorenal ligament. In this case perhaps the ligaments were more lax than normal. She made an uneventful recovery. Viral screening done post-operatively was negative. The spleen measured 12 cm � 8c m� 5 cm, and weighed 114 g. Microscopy showed expansion and congestion of the red pulp with numerous neutrophils. No other pathological feature was found.