Atraumatic Splenic Rupture Research Articles

Spontaneous splenic rupture in an acute leukemia patient with splenic tuberculosis: A case report

Spontaneous splenic rupture, also referred to as atraumatic splenic rupture, is a rare but life-threatening emergency condition. Without timely diagnosis and treatment, the mortality rate of splenic rupture approaches 100%. The etiology of atraumatic splenic rupture varies; it is reportedly associated with neoplasms or splenic infection, but is rarely encountered in patients with both conditions. We herein report the case of a 58-year-old male patient with acute myeloid leukemia (AML) complicated by splenic tuberculosis (TB), who presented with spontaneous rupture of the spleen. Pathological examination of the resected spleen revealed multifocal granulomatosis with caseous necrosis. However, with timely diagnosis and surgical intervention, the patient recovered successfully and is currently on consolidation therapy. To the best of our knowledge, this is the first case of spontaneous splenic rupture in AML with splenic TB. The relevant literature on spontaneous splenic rupture was also reviewed and the potential etiology and treatment were discussed.

Atraumatic Splenic Rupture: An Unusual Presentation of Hairy Cell Leukemia

Spontaneous splenic rupture is an uncommon but life threatening acute emergency. Up to one half cases of Atraumatic splenic rupture (ASR) are preceded by splenomegaly. Hematological malignancies can present with splenomegaly and have clinical features of left upper quadrant (LUQ) pain and fullness. Abdominal pain is one of the commonest reasons for consulting Gastroenterology in the in-patient setting. We present a case of a patient who developed symptoms due to ASR which was not evident on initial imaging. While there are multiple causes of ASR, neoplastic etiologies account for about a third of these cases. Hairy Cell Leukemia (HCL) is a rare lymphoid neoplasm which often presents with nausea, vomiting, and LUQ pain. Splenomegaly is a common manifestation of this disease, although ASR occurs much less frequently. This report highlights a case of a 64-year-old woman with known comorbidities of hypertension and diabetes, who presented with persistent nausea, vomiting and epigastric pain, for one week. Prior to presentation, she had complained of intermittent abdominal pain for 16 months. A computerized tomography (CT) scan of abdomen done a year earlier had revealed a nonspecific wedgeshaped, low attenuating lesion in the spleen- suspicious for a splenic infarct. On examination, she was hemodynamically stable, with mild discomfort in the LUQ and palpable splenomegaly which was confirmed by imaging studies. The patient was thought to have gastroparesis secondary to uncontrolled diabetes mellitus, and was being treated conservatively. Patient was then noted to have a significant drop in Hematocrit without signs of active gastrointestinal bleeding. Her abdomen became distended with moderate LUQ tenderness. A repeat CT scan of abdomen showed evidence of intraperitoneal hemorrhage. The patient underwent emergent angiography and a bleeding splenic vessel was identified and embolized. She underwent an open splenectomy for ASR. A 6 cm laceration was found on the lower pole of the spleen. Pathology of the specimen unexpectedly returned positive for HCL. Patients with splenomegaly often present with symptoms of nausea, vomiting, and minimal LUQ tenderness. Careful clinical evaluation and urgent investigations should be undertaken in these patients as they may develop serious complications. ASR is an important and life threatening complication which may develop acutely or insidiously and should be monitored for in any patient with splenomegaly of unknown cause.Figure 1Figure 2

Surgical management of atraumatic splenic rupture

Atraumatic splenic rupture (ASR) is a rare, spontaneous, and potentially life-threatening condition that occurs in the absence of trauma; yet the management of ASR has largely defaulted to the treatment algorithm related to blunt splenic trauma. Our aim is to determine if it is appropriate and safe to use the treatment algorithm for blunt splenic trauma in the management of both pathological and non-pathological ASR. We present a case of non-pathological ASR that was successfully managed without splenectomy. A comprehensive literature review on spontaneous ASR was also performed to include publications from January 1975 to February 2015. 914 total cases of ASR were identified: 70 non-pathological and 844 pathological. Overall, 86.5% of these patients received splenectomy based on the presence or absence of traditional signs of clinical instability or deterioration, as utilized in cases of traumatic splenic rupture. There were only 11 non-pathological cases detailed. Unlike our present case, all of these cases resulted in splenectomy. The present case is that of a 37 year-old man with grade III splenic rupture, successfully managed without surgery or splenectomy. Details regarding ASR patients are limited in current literature. The majority of patients with ASR will receive splenectomy, regardless of etiology. Our review would suggest that it is appropriate and safe to pursue conservative non-surgical therapy in select patients who present with ASR of any given etiology (even non-pathological), while utilizing the same indications for splenectomy used in cases of blunt abdominal trauma.

A Case of a Chronic Pancreatic Pseudocyst Causing Atraumatic Splenic Rupture without Evidence of Acute Pancreatitis.

Atraumatic splenic rupture is a rare complication of a pancreatic pseudocyst (PP), described in the setting of chronic pancreatitis. There is common understanding, within the literature, that an inflammatory process at the tail of the pancreas may disrupt the spleen and result in such splenic complications. The authors present a case report of a 29-year-old male with a PP, associated with chronic pancreatitis. The patient had a history of excessive alcohol intake and presented to the emergency department with a short history of abdominal pain and vomiting. He denied any significant history of trauma and serum amylase levels were normal. An admission computed tomography (CT) scan of the abdomen confirmed the presence of a PP in direct contact with the spleen. The CT also demonstrated a heterogenous hypodense area of the splenic hilum, along with perisplenic fluid. The patient was admitted for observation. His abdominal pain progressed, and he became haemodynamically unstable. An emergency ultrasound scan (USS) at this time revealed intra-abdominal haemorrhage. A subsequent CT confirmed splenic rupture, which was managed surgically with a full recovery. Few such cases are documented within the literature and more understanding of preempting such events is needed.

ATraumatic Splenic Rupture: Dreaded Complication of Splenomegaly

We discuss the causes of splenomegaly and the underlying abnormalities leading to the most feared complication of a traumatic splenic rupture. A case discussion is included.

Atraumatic splenic rupture cases presenting with hemorrhagic shock and coagulopathy treated by splenic artery occlusion using a microballoon catheter before splenectomy

Atraumatic splenic rupture (ASR) is an uncommon pathologic condition in which bleeding from the spleen occurs for a variety of nontraumatic reasons. While the current trend in traumatic splenic rupture is nonoperative management including transcatheter arterial embolization, the current recommendation for the treatment of most patients with ASR is splenectomy. In this report, we describe two cases of ASR presenting with hemorrhagic shock and complicated by anticoagulation therapy. In patients with severe hemorrhagic shock and coagulopathy, a damage control strategy is recommended. Our successful treatment of these patients included a three-step strategy as a damage control: (i) rapid transient hemostasis by splenic artery occlusion using a microballoon catheter, (ii) damage control resuscitation and (iii) splenectomy as a definitive hemostatic treatment.

A rare cause of syncope: The atraumatic splenic rupture

A rare cause of syncope: The atraumatic splenic rupture

Atraumatic splenic rupture from Babesia: A disease of the otherwise healthy patient

Babesiosis, an infection caused by the protozoan Babesia microti and transmitted by the Ixodes scapularis tick, is commonly described in the literature with an approximate incidence of 1000 cases per year (Herwaldt et al., 2012). Infections in North America occur most frequently during the spring and summer months in the Northeastern and Midwestern United States. Babesia can cause a wide spectrum of clinical manifestations ranging from a self-limited febrile illness or mild anemia to severe illness causing acute respiratory distress syndrome (ARDS), disseminated intravascular coagulopathy (DIC) and multisystem organ failure. Severe illness most commonly occurs in elderly, immunocompromised, or asplenic patients (Vannier and Krause, 2012). Splenic rupture has been generally described as a complication of severe illness secondary to babesiosis. We describe a case of spontaneous splenic rupture in an otherwise healthy woman that required emergent splenectomy. Recent case reports suggest that splenic rupture occurs in people without known risk factors for severe babesiosis. Physicians should be aware of this acute presentation in otherwise healthy individuals.

Spontaneous Splenic Rupture: First Presentation of Alcoholic Steatohepatitis

Case Report: A 56-year-old Caucasian woman with history of moderate alcohol intake presented with sudden-onset, severe abdominal pain with nausea and dizziness for a few hours. On examination, she was afebrile, hypotensive, tachycardic, and icteric. There were multiple spider angiomata over the chest. She had tenderness and guarding in the epigastrium and left upper quadrant without rigidity. Rectal vault had brown stool that was guaiac negative. Lab data were: hemoglobin 7.6 mg/dL (down from 14 mg/dL six months ago); platelet 238,000/μL; total bilirubin 7.7 mg/dL; AST 135 IU/L; albumin 2.6 g/dL; and INR 1.3. CT abdomen showed an enlarged echogenic liver and a normal-appearing pancreas. Spleen had a rupture postero-inferiorly with resultant perisplenic hematoma. After taking resuscitative measures, an urgent exploratory laparotomy showed splenic rupture in multiple pieces, still connected to the hilum with massive hemoperitoneum of 1.5 L and hepatomegaly. A splenectomy and wedge liver biopsy was done. Liver histopathology showed extensive steatosis (80-90%), ballooning degeneration, severe cholestasis, Mallory-hyaline, and mixed inflammatory infiltrate. Trichrome stain highlighted extensive sinusoidal and portal fibrosis with focal areas of bridging fibrosis. Splenic histopathology showed capsular disruption with subcapsular and intraparenchymal hemorrhage, and acute inflammation. Etiological work-up for liver disease and splenic rupture including serum copper, viral panel, hemochromatosis screen, alpha-1 antitrypsin, autoimmune panel, monospot, leukemia, and lymphoma panel was negative. Cause of her splenic rupture was felt to be related to portal hypertension from alcoholic steatohepatitis and early cirrhosis. Discussion: Non-traumatic splenic rupture (NSR) is a rare, but life threatening condition. Diagnosis is often suspected based on clinical symptoms. Paracentesis with aspiration of fresh blood is useful to diagnose intraperitoneal hemorrhage. Abdominal ultrasound is especially useful in hemodynamically unstable patients. CT can shows grade of splenic damage severity and intraperitoneal free fluid. In a review of 845 cases of NSR, the spleen was normal in 7%. The major pathologic etiological groups were neoplastic (30%), infectious (27%), and inflammatory (20%). In our patient, we ascribed the splenic rupture to congestion resulting from steatohepatitis. This patient had patent portal and splenic vein, ruling out congestion due to thrombosis. This is a unique case for rarity of atraumatic splenic rupture as presenting manifestation of steatohepatitis with early changes of bridging fibrosis.

Cocaine-associated hemoperitoneum following atraumatic splenic rupture: a case report and literature review

IntroductionSplenic hematoma or rupture of the spleen is rare in the absence of trauma. This case report with a brief review of the literature is intended to raise awareness of splenic bleeding as an etiology of abdominal pain; it highlights the importance of a detailed social history.Presentation of caseThis report of an otherwise healthy 42-year old man details hemoperitoneum with splenic rupture as a cause for hemorrhage following cocaine use. The patient was managed non-operatively in the surgical intensive care unit. He did not require transfusion and was discharged home on hospital day four with close follow-up.DiscussionWhile splenic pathology associated with cocaine use has been described, this case illustrates a novel report of cocaine-associated splenic hemorrhage. A plausible mechanism is transient vasospasm with subsequent bleeding into the infarcted area.ConclusionAlthough uncommon, atraumatic splenic rupture should be recognized early because it is potentially fatal. This case is the first to describe hemoperitoneum of splenic etiology following cocaine use.

Spontaneous (atraumatic) splenic rupture complicating anticoagulant treatment for splenic infarction

Summary We report the case of a 61-year-old male patient who suff ered a spontaneous (atraumatic) splenic rupture (SSR) following splenic infarction treated by heparin anticoagulation. Splenic rupture precipitated by thrombolytic or anticoagulant therapy has been reported and putatively attributed to unrecognized micro-traumatisms i.e. after resuscitation manoeuvres, leading to massive bleeding upon anticoagulation and secondary splenicrupture. Nevertheless, SSR resulting from splenic infarction and anticoagulation has not been described.

Atraumatic splenic rupture secondary to chronic HIV infection

As patients infected with HIV live longer due to effective anti-retroviral therapy, new disease manifestations are becoming apparent. We describe the case of a 59-year-old patient who presented to our unit with atraumatic splenic rupture secondary to chronic HIV infection. Given the high mortality associated with atraumatic splenic rupture, we believe it should be included in the differential diagnosis of HIV-positive patients presenting with acute abdominal pain.

Hoof Beats May Mean Zebras: Atraumatic Splenic Rupture

Hoof Beats May Mean Zebras: Atraumatic Splenic Rupture

Spontaneous (Atraumatic) Splenic Rupture

The spleen is an organ that often ruptures after blunt abdominal trauma. Unlike traumatic splenic rupture, spontaneous (atraumatic) splenic rupture is a rare and life-threatening condition. In the present study, a case who was admitted to the emergency depertment with complaints of abdominal pain, nausea and vomiting was diagnosed as spontaneous rupture of spleen. This case is dicussed in light of the literature

Atraumatic Splenic Rupture: An Unusual Manifestation of Acute HIV Infection

A 27-year-old white male, who had sex with other men, presented to the emergency department with 3 days of left shoulder and abdominal pain. He reported no history of trauma to the abdomen. On abdominal imaging, he was found to have hemoperitoneum from a ruptured spleen; he underwent splenectomy. Causes of atraumatic splenic rupture can be divided into six main categories: infectious, neoplastic, inflammatory, congenital or structural, iatrogenic, and idiopathic. Work-up of the atraumatic splenic rupture revealed that his HIV antibody was newly positive. He had a documented negative HIV antibody 3 weeks prior to the current admission. CD4 cell count, obtained after splenectomy, was 904 cells per microliter and the HIV-1 plasma RNA level was 4657 copies per milliliter. Spleen pathology demonstrated an enlarged spleen with increase in the number of small to intermediate size lymphoid cells in the red pulp, and reactive follicular lymphoid hyperplasia, with numerous secondary lymphoid follicles and reactive germinal centers in the white pulp. T-cell receptor (TCR) gene rearrangement studies demonstrated a positive TCR beta gene rearrangement, without a TCR gamma gene rearrangement, consistent with a clonal CD8(+) T-cell population. The case gives rare insight into what happens in the spleen during acute HIV infection and encourages HIV testing in those presenting with atraumatic splenic rupture. Counseling patients with acute HIV to avoid potential trauma should also be considered.

Atraumatic splenic rupture

Atraumatic splenic rupture is an uncommon but poorly defined clinical condition. Its diagnosis may be missed or delayed because of low clinical suspicion, especially in the absence of trauma. The primary aim of this study was to describe the experience with atraumatic splenic rupture in a district general hospital. Over a 6-year period (2004-2010), seven patients were identified, producing an incidence of 1.2/year. Computed tomography confirmed the diagnosis preoperatively in all the cases where it was performed (n=5). All patients required total splenectomy; indications included peritonitis, hypovolaemic shock and failed conservative treatment. Five splenectomies were performed within 24 h of admission. In four cases, no pathological abnormality was identified (atraumatic-idiopathic); abnormal pathologies (atraumatic-pathological) in the remaining three were amyloidosis, lymphoma and focal thrombosis. A high index of suspicion should be maintained by emergency physicians and surgeons during initial evaluation of these patients. Computed tomography scan facilitates the diagnosis and early total splenectomy is often needed.

Acquired A amyloidosis from injection drug use presenting with atraumatic splenic rupture in a hospitalized patient: a case report

IntroductionLittle is known about splenic rupture in patients who develop systemic acquired A amyloidosis. This is the first report of a case of atraumatic splenic rupture in a patient with acquired A amyloidosis from chronic injection drug use.Case presentationA 58-year-old Caucasian man with a long history of injection drug use, hospitalized for infective endocarditis, experienced atraumatic splenic rupture and underwent splenectomy. Histopathological and microbiological analyses of the splenic tissue were consistent with systemic acquired A amyloidosis, most likely from injection drug use, that led to splenic rupture without any recognized trauma or evidence of bacterial embolization to the spleen.ConclusionIn patients with chronic inflammatory conditions, including the use of injection drugs, who experience acute onset of left upper quadrant pain, the diagnosis of atraumatic splenic rupture must be considered.

Splenic Rupture as a Complication of Autologous Hematopoietic Cell Transplantation In a Patient with Systemic Amyloidosis.

AbstractAbstract 4528 Background:Atraumatic splenic rupture is a known complication of amyloidosis. We report a female patient with amyloidosis who developed spontaneous splenic rupture in the peri transplant period. Case report:A 56 years old Caucasian woman presented with renal failure (creatinine 1.7 mg/dL) and nephrotic-range proteinuria (3.6 grams in 24 hours). Renal biopsy showed mesangial expansion with increased diffuse infiltrate and Congo red stain positivity consistent with renal amyloidosis. Bone marrow (BM) biopsy showed 5% plasma cells. Pre-transplant CT scan showed hepatosplenomegaly. 13.16 million CD34+ cells/kg of G-CSF mobilized progenitor cells were collected without complications. She received high dose melphalan at 200 mg/m2 followed by autologous hematopoietic cell transplantation (HCT). On post transplant day +8, she developed initial intraperitoneal hemorrhage from spontaneous splenic rupture. The post-transplant course was complicated with tracheal intubation, worsening renal failure requiring hemodialysis, and episodic hypertensive episodes with posterior reversible encephalopathy syndrome, making her a poor candidate for immediate surgical intervention. A day +60 BM biopsy showed normal cellularity with mild megakaryocytic hyperplasia. There was amyloid deposition in 30% of marrow space by Congo red stain. She underwent exploratory laparotomy and splenectomy on day +70 post transplant. Spleen was enlarged, measuring 18 × 15 × 9 cm in size, and weighed 1630 grams. There were multiple areas of hemorrhage and necrosis with multifocal and extensive nodular deposition of pink, amorphous, and waxy material. Congo red stain showed apple-green birefringence in associated collagen and vessel walls. Thioflavin T was strongly positive, confirming the presence of amyloid. No evidence of lymphoproliferative disorder or plasma cell dyscrasia was seen. The patient developed rebleeding and was treated with aminocaproic acid and multiple platelet transfusions. Her post transplant course has been further complicated with the development of autoimmune hemolytic anemia and immune thrombocytopenic purpura, consistent with Evans syndrome. She required treatment with corticosteroids, intravenous immunoglobulin, rituximab and colchicine. More than five months from her transplant, the patient is alive, independent of transfusion support, and in complete remission. Discussion:Splenic involvement in amyloidosis is rather frequent (5-10%). However, an atraumatic rupture of the affected spleen is thought to be an extremely rare event. There have been only 5 published cases of spontaneous splenic rupture in the context of autologous HCT in patients with amyloidosis (Am J Hematol 2003;74:131-135, Eur J Haematol 2008;80:182-184, Wien Klin Wochenschr 2006;118:49-53). One case was associated with G-CSF stem cell mobilization. The range of timing of splenic rupture in reported cases was day +1 to +23 post transplant. The reported spleen weight ranged from 159 to 450 grams. Most patients had elevated white blood cell count at the time of rupture. Although the occurrence of atraumatic splenic rupture in amyloid patients has been described, spontaneous splenic rupture in the context of autologous HCT still remains rare. Transplant physicians should maintain high index of suspicion for spontaneous splenic rupture in amyloid patients and laparoscopic splenectomy can be safely performed in the post-transplant period granted that their cardiac status can tolerate pneumoperitoneum. Disclosures:No relevant conflicts of interest to declare.

Spontaneous splenic rupture in an active duty Marine upon return from Iraq: a case report

IntroductionAtraumatic splenic rupture is a rare event that has been associated with several infectious disease processes. In the active duty military population, potential exposure to these pathogens is significant. Here we discuss the case of an active duty Marine with spontaneous splenic rupture upon return from a six-month deployment in Iraq.Case presentationA previously healthy 30-year-old Caucasian male active duty Marine presented with abdominal pain, fever and diarrhea after deployment to Iraq in support of Operation Iraqi Freedom. Based on clinical and radiographic evidence, a diagnosis of spontaneous splenic rupture was ultimately suspected. After exploratory laparotomy with confirmation of rupture, splenectomy was performed, and the patient made a full, uneventful recovery. Histopathologic examination revealed mild splenomegaly with a ruptured capsule of undetermined cause.ConclusionSpontaneous splenic rupture is a rare event that may lead to life-threatening hemorrhage if not diagnosed and treated quickly. Although the cause of this patient's case was unknown, atraumatic splenic rupture has been associated with a variety of infectious diseases and demonstrates some risks the active duty military population may face while on deployment. Having an awareness of these pathogens and their role in splenic rupture, clinicians caring for military personnel must be prepared to recognize and treat this potentially fatal complication.

Authors' reply: Systematic review of atraumatic splenic rupture (Br J Surg 2009; 96: 1114–1121)

Authors' reply: Systematic review of atraumatic splenic rupture (<i>Br J Surg</i> 2009; 96: 1114–1121)