Pathologic splenic rupture: an unusual presentation of pancreatic cancer

Splenic rupture due to metastatic disease: a rare complication

We report a case of splenic rupture in an 83-year-old woman presenting with symptoms concerning for upper gastrointestinal malignancy. CT imaging revealed marked gastric thickening and a 33×33 mm splenic metastasis, with subsequent gastroscopy demonstrating a large lesion at the gastro-oesophageal junction. While awaiting further investigation, the patient developed acute onset left upper quadrant pain, peritonism and hypovolaemic shock. Urgent CT imaging demonstrated a ruptured spleen with extensive haemoperitoneum, necessitating emergency splenectomy.

613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review

BACKGROUND

Rupture of the spleen in the absence of trauma or previously diagnosed disease is largely ignored in the emergency literature and is often not documented as such in journals from other fields. We have conducted a systematic review of the literature to highlight the surprisingly frequent occurrence of this phenomenon and to document the diversity of diseases that can present in this fashion.

METHODS

Systematic review of English and French language publications catalogued in Pubmed, Embase and CINAHL between 1950 and 2011.

RESULTS

We found 613 cases of splenic rupture meeting the criteria above, 327 of which occurred as the presenting complaint of an underlying disease and 112 of which occurred following a medical procedure. Rupture appeared to occur spontaneously in histologically normal (but not necessarily normal size) spleens in 35 cases and after minor trauma in 23 cases. Medications were implicated in 47 cases, a splenic or adjacent anatomical abnormality in 31 cases and pregnancy or its complications in 38 cases. The most common associated diseases were infectious (n = 143), haematologic (n = 84) and non-haematologic neoplasms (n = 48). Amyloidosis (n = 24), internal trauma such as cough or vomiting (n = 17) and rheumatologic diseases (n = 10) are less frequently reported. Colonoscopy (n = 87) was the procedure reported most frequently as a cause of rupture. The anatomic abnormalities associated with rupture include splenic cysts (n = 6), infarction (n = 6) and hamartomata (n = 5). Medications associated with rupture include anticoagulants (n = 21), thrombolytics (n = 13) and recombinant G-CSF (n = 10). Other causes or associations reported very infrequently include other endoscopy, pulmonary, cardiac or abdominal surgery, hysterectomy, peliosis, empyema, remote pancreato-renal transplant, thrombosed splenic vein, hemangiomata, pancreatic pseudocysts, splenic artery aneurysm, cholesterol embolism, splenic granuloma, congenital diaphragmatic hernia, rib exostosis, pancreatitis, Gaucher's disease, Wilson's disease, pheochromocytoma, afibrinogenemia and ruptured ectopic pregnancy.

CONCLUSIONS

Emergency physicians should be attuned to the fact that rupture of the spleen can occur in the absence of major trauma or previously diagnosed splenic disease. The occurrence of such a rupture is likely to be the manifesting complaint of an underlying disease. Furthermore, colonoscopy should be more widely documented as a cause of splenic rupture.

Imaging findings of ruptured abdominal and pelvic tumors

A variety of abdominal and pelvic tumors can present with rupture leading to hemoperitoneum/hemoretroperitoneum or peritonitis. Imaging plays an important role in the diagnosis of hemorrhage or peritonitis as well as in the detection of ruptured tumors or organs. In this article, we illustrate the imaging findings of ruptured tumors arising in the abdominal and pelvic organs while excluding those of ruptured tumors arising in the stomach and intestines. It is important for the radiologists to understand the mechanisms involved in tumor rupture and recognize the imaging features of ruptured tumors according to the organs involved because this will permit the exact diagnosis of ruptured tumors, thereby facilitating prompt and effective treatment.

[Atraumatic rupture of the spleen: experience of 10 cases]

The most common cause of splenic rupture is trauma. Less frequently the spleen ruptures due to an ongoing hematologic, infectious or tumoral disease (pathologic rupture). We present a series of 10 patients with atraumatic splenic rupture: in seven patients there was a pathologic rupture. Two of the remaining three patients with spontaneous rupture were morbidly obese; this association has not previously been reported. The present review discusses the etiology, pathogenesis and optimal treatment of this entity.

Splenic rupture: a rare presentation of pancreatic carcinoma

CONTEXT

Splenic rupture secondary to solid malignancy is an infrequent complication that usually occurs late in the progression of a previously diagnosed cancer. In rare instances, splenic rupture precipitates the discovery of an unsuspected pancreatic carcinoma. We report 2 cases of adenocarcinoma of the pancreas in which the patients presented with splenic rupture.

OBJECTIVES

To review the clinicopathologic features of splenic rupture due to pancreatic carcinoma and to increase awareness of malignancy as a possible etiology for atraumatic splenic rupture.

DESIGN

We reviewed the clinical and pathologic data from 2 patients. A literature search was conducted to identify previous reports of splenic rupture associated with pancreatic cancer. We summarized the characteristics of the earlier cases and compared them with those of our patients.

RESULTS

We found only 4 previous reports of splenic rupture preceding the diagnosis of pancreatic cancer. In 3 of these cases, the pancreatic carcinoma grossly invaded the spleen at the time of resection. In contrast, malignancy was not suspected as the etiology of the rupture in our patients until histologic examination of the resected spleen revealed carcinoma.

CONCLUSION

Splenic rupture is an unusual presentation of cancer of the pancreas, and to our knowledge only 4 cases have been reported previously in the literature. Although an underlying malignancy is relatively rare, spleens resected for atraumatic rupture should be carefully examined for possible neoplastic etiologies.