Spontaneous rupture of the spleen: three case reports and causative processes for the radiologist to consider

Atraumatic splenic rupture in COVID-19 era: case report and systematic literature review

Atraumatic splenic rupture is a rare but life-threatening condition. The Coronavirus disease 2019 (COVID-19) is still a mysterious infection, often associated with spontaneous bleeding and coagulation disorders. Among them, a rare presentation is the atraumatic splenic rupture during SARS-CoV-2 infection. We reported the case of a COVID-19 patient that underwent splenectomy for a spontaneous splenic rupture without splenomegaly or any hematological disorders. Moreover, we reviewed the literature about this matter focusing on the hypothetical etiopathogenesis of this condition in COVID-19 patients. Twelve cases of atraumatic splenic rupture without splenomegaly were reported in ten papers. Coughing, respiratory tract infections and anticoagulant treatment were postulated as the main risk factors for the spontaneous splenic rupture. COVID-19 is still a not well-known disease with multiple clinical presentations. The spontaneous splenic rupture is uncommon in general population but this event should not be neglected in this particular subset of patients.

Atraumatic splenic rupture in a patient treated with rivaroxaban: A case report and a narrative review

Atraumatic splenic rupture (ASR) is a rare condition mostly associated with neoplastic, infectious, and inflammatory diseases. ASR associated with drug treatment is even rarer. In this case report, we highlight an unusual complication of the direct oral anticoagulant rivaroxaban. A 64‐year‐old male patient was admitted to the emergency department with complaints of faintness and diffuse abdominal cramps. The patient had no history of recent trauma. Clinical examination revealed hemodynamic instability with a moderate response to filling and mild abdominal discomfort on palpation. His medical history included chronic hypertension, constipation, and recent atrial flutter ablation. The patient was taking amiodarone, bisoprolol, atorvastatin, and rivaroxaban. Splenic rupture was diagnosed several hours later on contrast‐enhanced abdominal computed tomography scan. Massive blood transfusions and emergency laparotomy for splenectomy were performed. Anatomopathological analysis did not reveal any neoplastic, inflammatory, or infectious causes. The patient was successfully discharged from the intensive care unit 3 days later. Clinicians must consider the possibility of ASR as a complication of rivaroxaban in patients with abdominal tenderness and hemodynamic instability. Unfortunately, clinical presentation is not always typical of a ruptured spleen. Delayed diagnosis can be life threatening or fatal. Splenectomy via laparotomy remains the best therapeutic option in cases of splenic rupture in unstable patients on direct oral anticoagulants.

Adolescent With Spontaneous Splenic Rupture as a Cause of Hemoperitoneum in the Emergency Department: Case Report and Literature Review

Spontaneous rupture of the spleen is a rare clinical condition that usually presents as a complication of a background pathology and can become a life-threatening condition if it is not diagnosed in time. We present the case of a 15-year-old girl with abdominal pain and clinical data of hypovolemic shock. The simple tomographic study revealed deformation of the splenic architecture and hemoperitoneum. Surgery demonstrated splenic rupture with ptosis spleen and intraperitoneal free blood. The anatomopathological examination showed the presence of splenomegaly and findings suggestive of peliosis. It also highlights the known causes related to spontaneous splenic rupture.

Atraumatic splenic rupture precipitated by splenic vein thrombosis

We present the case of a 59-year-old man with atraumatic splenic rupture because of splenic vein thrombosis who was successfully treated with splenic artery embolization.

Occult splenic rupture in a case of chronic calcific pancreatitis with a brief review of literature

INTRODUCTION

Splenic rupture in chronic pancreatitis is a life threatening rare complication. The anatomical proximity of the pancreas with the spleen and the pathophysiological process in acute and chronic pancreatitis form the basis of this dreaded complication.

PRESENTATION OF CASE

We cite the case of a young male previously undiagnosed with chronic pancreatitis presenting with atraumatic splenic rupture. Definitive diagnosis was made by contrast enhanced computed tomography of the abdomen, intra operative findings, and histopathological examination of the splenectomy specimen.

DISCUSSION

The splenorenal ligament forms the main anatomic proximity between the pancreas and the spleen. A few pathophysiological mechanisms though suggested are incompletely understood. splenic vein thrombosis, intrasplenic pseudocysts, splenic rupture, infarction, necrosis, splenic hematoma, and severe bleeding from eroded splenic vessels are the complications noted of which splenic rupture is the second most common following splenic vein thrombosis forming 36% of the complications noted. Chronic pancreatitis as an etiology of occult splenic rupture is rare and forms 8.27% of cases; commonest causes being neoplastic and infectious. The diagnosis is based on clinical and radiological findings and the management is predominantly surgical.

CONCLUSION

High clinical suspicion on the part of the treating physician and the emergency team is essential to the management of atraumatic splenic rupture. The increasing understanding of the pathophysiology and presentation of splenic complications in pancreatitis may alert the index physician to these fatal complications.

Spontaneous rupture of the spleen masquerading as a pulmonary infection

Atraumatic rupture of a normal spleen represents a rare clinical phenomenon. We report on an atypical presentation of a spontaneous splenic rupture in a 44-year-old previously healthy Greek male admitted to the emergency department due to left-sided pleuritic thoracic pain in the course of a pneumonia diagnosed 2 days before. During his stay, pain extended to the epigastric region. Abdominal examination revealed generalized tenderness. We presume that coughing secondary to respiratory infection was the main factor that precipitated splenic rupture. Despite the rarity of the condition physicians have to consider the diagnosis of spontaneous nontraumatic splenic rupture when they encounter healthy patients with nonspecific lower thoracic or abdominal pain. Prompt diagnosis is essential for a better outcome.

Spontaneous hemoperitoneum

Spontaneous hemoperitoneum is a rare, but life-threatening condition usually caused by nontraumatic rupture of the liver, spleen, or abdominal vasculature with underlying pathology. Management revolves around angioembolization or surgical intervention. This article provides a brief overview of the diagnosis and treatment of this disorder.

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

Introduction

Splenic 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 case

This 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.

Discussion

While 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.

Conclusion

Although 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.

Unusual presentation of spontaneous splenic haematoma due to severe pancreatitis: a cautionary tale

We report the case of a patient with multiple splenic complications from chronic pancreatitis with pseudocyst formation, including splenic vein thrombosis, subcapsular splenic haematoma and splenic artery pseudoaneurysm. The initial presentation was associated with pleuritic chest pain, clinically resembling symptoms of pulmonary embolism. The patient was treated with therapeutic low-molecular-weight heparin, without confirmatory imaging. However, the latter arranged computed tomographic pulmonary angiogram was negative, while the abdominal sequences of the CT revealed the splenic haematoma as causative pathology. The patient was initially treated conservatively, and discharged from inpatient care. On a subsequent CT, a pseudoaneurysm of the splenic artery was found and treated with coil embolisation. The patient is currently awaiting definitive management of the pancreatic pseudocyst.

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.

A case of spontaneous splenic rupture during chemotherapy for B-cell chronic lymphoid leukemia

Spontaneous splenic rupture is a life-threatening disease and an important differential diagnosis of acute abdomen. Early clinical diagnosis and rapid intervention is required to ensure patient survival. Spontaneous splenic rupture may be induced by hematological, inflammatory or infiltrative diseases affecting the spleen. Splenomegaly may also significantly increase the risk of rupture. Other contributory factors include male, adulthood, rapid growth of the spleen and splenic abscess. Here, we present the case of a 69-year-old man who was undergoing chemotherapy for B-cell chronic lymphoid leukemia. He was admitted to our hospital after he suddenly developed persistent upper abdominal pain. Computed tomography and ultrasonography revealed accumulation of free fluid in and around the spleen. He was diagnosed as having spontaneous splenic rupture and an emergency operation was performed. During the operation, we found a massively enlarged spleen with several capsular tears, and performed a splenectomy. The patient made a good recovery. Pathological examination revealed that the spleen was infiltrated by CD20-, CD5- and CD23-positive lymphoid blasts. We encountered a case of spontaneous splenic rupture in a patient receiving chemotherapy for exacerbating B-cell chronic lymphoid leukemia. In a case of abdominal pain of acute onset in patients with hematological disease, spontaneous splenic rupture should be suspected.

Two rare cases of spontaneous splenic rupture

The rupture of the spleen, not secondary to external trauma, is rare. Two cases are reported. The first case occurred in a patient with an aggressive form of lymphoma, and the second in a patient following a colonoscopy. In the rare occurrences of spontaneous rupture, radiological imaging, in particular by computed tomography, will lead to the diagnosis and help in deciding the correct treatment.