Atraumatic Splenic Hemorrhage as a Rare Complication of Pancreatitis: Case Report and Literature Review

[Acute necrotizing pancreatitis with hemorrhagic shock in secondary splenic rupture: a case report and literature review]

Atraumatic splenic rupture is a rare complication of acute and chronic pancreatitis. It arises due to its anatomical proximity to the pancreas, for instance, due to erosion of large pseudocysts or walled-of-necrosis (WON).Following we describe the case of a 62-year-old woman who presented for further diagnostics and treatment of acute pancreatitis with the development of large walled-of necrosis (WON) in the pancreatic corpus and tail. During the course, the patient developed a hemorrhagic shock. An emergency computer tomography (CT) of the abdomen revealed a ruptured spleen with a large capsular hematoma with no evidence of active bleeding. In contrast to previous published case reports, our treatment was exclusively minimal-invasive: by radiological guided embolization of the splenic artery and by endosonographic guided implantation of a lumen apposing metal stent (LAMS). The splenic hematoma was spontaneously regressive without secondary drainage.

Complications of chronic pancreatitis prior to and following surgical treatment: A proposal for classification

BACKGROUND

Chronic pancreatitis (CP) is a long-lasting disease frequently associated with complications for which there is no comprehensive pathophysiological classification.

AIM

The aims of this study were to: Propose a pathophysiological classification of the complications of CP; evaluate their prevalence in a surgical cohort prior to, and following surgical management; and assess the impact of the surgical treatment on the occurrence of new complications of CP during follow-up. We hypothesized that optimal surgical treatment can resolve existing complications and reduce the risk of new complications, with the exclusion of pancreatic insufficiency. The primary outcomes were prevalence of complications of CP at baseline (prior to surgical treatment) and occurrence of new complications during follow-up.

METHODS

After institutional review board approval, a prospective observational cohort study with long-term follow-up (up to 20.4 years) was conducted. All consecutive single-center adult patients (≥ 18 years of age) with CP according to the criteria of the American Pancreas Association subjected to surgical management between 1997 and 2021, were included. The prevalence of CP complications evaluated, according to the proposed classification, in a surgical cohort of 166 patients. Development of the pathophysiological classification was based on a literature review on the clinical presentation, course, and complications of CP, as well a review of previous classification systems of CP.

RESULTS

We distinguished four groups of complications: Pancreatic duct complications, peripancreatic complications, pancreatic hemorrhages, and pancreatic insufficiency (exocrine and endocrine). Their baseline prevalence was 20.5%, 23.5%, 10.2%, 31.3%, and 27.1%, respectively. Surgical treatment was highly effective in avoiding new complications in the first and third groups. In the group of peripancreatic complications, the 15-year Kaplan-Meier prevalence of new complications was 12.1%. The prevalence of pancreatic exocrine and endocrine insufficiency increased during follow-up, being 66.4% and 47.1%, respectively, at 15 years following surgery. Pancreatoduodenal resection resulted optimal results in avoiding new peripancreatic complications, but was associated with the highest rate of pancreatic exocrine insufficiency.

CONCLUSION

The proposed complication classification improves the understanding of CP. It could be beneficial for clinical decision making, as it provides an opportunity for more comprehensive judgement on patient’s needs on the one hand, and on the pros and cons of the treatment under consideration, on the other. The presence of complications of CP and the risk of development of new ones should be among the main determinants of surgical choice.

Chronic lymphocytic leukemia, a rare cause of spontaneous rupture of the spleen

INTRODUCTION

Spleen Spontaneous Rupture SRS is a rare phenomenon in which the spleen ruptures without associated trauma. This pathology is rarely caused by Chronic Lymphocytic Leukemia.

PRESENTATION OF THE CASE

We present a case of a 59-year-old male patient with chronic Lymphocytic Leukemia, who was admitted with an acute abdomen whose clinical and paraclinical examinations revealed a spleen spontaneous rupture. The treatment consisted of a splenectomy.

DISCUSSION

Spontaneous spleen rupture was first described by Rokitansky in 1861 and mentioned in many cases since, the common causes of non-traumatic Splenic rupture include myeloproliferative diseases, vasculitis, and infections. However, Chronic Lymphocytic Leukemia (CLL) remains an obscure cause of splenic rupture that requires unique attention. The diagnosis of splenic rupture should be considered in all patients with hematologic malignancies presenting with abrupt onset of abdominal pain, hemodynamic instability, or acute anemia. The choice between conservative treatment and splenectomy depends on different variables: the etiology of the SRS, the hemodynamic stability, the amount of packed red blood cells transfused. Thus, an interventional approach can be advocated for a spontaneous splenic rupture over nonoperative management. Splenic embolization can provide patients with the advantages of both operative splenectomy and conservative management. The mortality rate from SRS is 12.2 %. Neoplastic pathologies were most significantly associated with fatal outcomes.

CONCLUSION

The high mortality rate seems to be mainly related to the delayed diagnosis and/or the severity of the underlying pathology. Given its seriousness, it requires a rapid diagnosis and adapted management.

Association of Atraumatic Splenic Rupture and Acute Pancreatitis: Case Report with Literature Review

Atraumatic splenic rupture is an uncommon complication of acute pancreatitis. This article presents a case of a 35-year-old patient presenting with acute pancreatitis who subsequently developed a splenic vein thrombosis and splenic rupture requiring a laparotomy and splenectomy. This rare but life-threatening complication requires prompt recognition and management in patients with pancreatitis who develop sudden hemodynamic instability.

A Rare Case of Atraumatic Splenic Rupture Due to Chronic Pancreatitis

Atraumatic splenic rupture is a rare but dangerous complication of chronic pancreatitis, vastly ignored in emergency literature. The anatomical relationship between the spleen and the tail of the pancreas contributes to the pathophysiology when an inflammatory process is in progress, although the mechanisms are not fully understood. The authors report the case of a 41-year-old male, previously undiagnosed with chronic pancreatitis, presenting with atraumatic splenic rupture. Due to worsening abdominal pain and hemodynamic instability, he underwent total splenectomy. The final diagnosis was obtained through contrast-enhanced abdominal computed tomography scans, intraoperative findings and histopathological examination of the surgical specimen, as frequently reported in previous cases. Total splenectomy is the treatment of choice, as the failure rate of the conservative approach is high. Few of these cases are described and a deeper understanding of the subject is needed. As this condition can worsen in a short time, a prompt diagnosis followed by adequate treatment can impact the morbidity and mortality associated with splenic rupture. High clinical suspicion is essential and increased knowledge about the pathophysiology and presentation of splenic complications in pancreatitis may alert emergency physicians to these fatal complications.

Splenic injury following endoscopic drainage of a large pancreatic pseudocyst: a case report

BACKGROUND

Many pancreatic pseudocysts spontaneously resolve, but larger or symptomatic pseudocysts may require procedural management. Though endoscopic ultrasound guided approaches are standard of care and have high success rates, complications can include bleeding, infection, and splenic perforation. This patient case report details an unusual series of complications of endoscopic cystogastrostomy that should encourage clinicians to evaluate for anatomic disruptions caused by mass effects of pancreatic pseudocysts prior to endoscopic pseudocyst drainage.

CASE PRESENTATION

A 53-year-old African American male with a past medical history notable for alcohol use disorder, chronic pancreatitis, and insulin dependent diabetes presented with a 4-day history of left upper quadrant abdominal pain. Computed tomography imaging with contrast revealed enlargement of a known pancreatic pseudocyst to 15.9 × 10.4 cm. Due to pseudocyst size and the patient's symptoms, endoscopic cystogastrostomy stent placement was performed. However, postprocedurally, he developed leukocytosis to 19,800 cells/m³ (from 14,100 cells/m³ preoperatively) as well as acute hypoxemic respiratory failure with a large left pleural effusion. Postprocedural computed tomography with contrast demonstrated a new large subcapsular splenic hematoma in communication with a new subdiaphragmatic fluid collection. Due to suspicion of endoscopic procedural complication, he underwent open laparotomy which revealed grade 4 splenic laceration, septic splenic hematoma, and a subdiaphragmatic abscess.

CONCLUSIONS

While endoscopic drainage of pancreatic pseudocyst was technically successful, this case demonstrates complications from mass effect of a large pancreatic pseudocyst which putatively tore the splenorenal ligament, leading to excessive separation of the left kidney and spleen. If anatomic disruptions caused by mass effect from a pancreatic pseudocyst are recognized through preprocedural abdominal imaging, such cases may be considered for early open repair versus cystogastrostomy.

Atraumatic splenic rupture in patient with acute pancreatitis

Atraumatic splenic rupture (ASR) is a rare complication of acute pancreatitis with high mortality and morbidity rates. We present a case of a 63-year-old woman with a history of hypertension, presenting with acute pancreatitis who subsequently developed a splenic rupture requiring a laparotomy and splenectomy. ASR is a rare but life-threatening complication requiring prompt recognition and management and should be considered in patient with pancreatitis who develops sudden haemodynamic compromise and worsening anaemia.

Case report of a spontaneous splenic rupture in a patient with chronic lymphocytic leukaemia treated by arterial splenic embolization

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SSR is an atraumatic event in which the spleen is damaged producing internal haemorrhage in the abdominal cavity.

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Actually the treatment of SSR is either surgical or conservative. Only few cases of radiological intervention are published in the literature.

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Splenic arterial embolization is a safe treatment option that allows rapid stabilization of the patient while offering both the benefits of splenectomy and conservative treatment.

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We present our experience of a case of SSR in a patient with chronic lymphocytic leukaemia managed by emergency embolization and elective surgery.

Introduction and importance

Spontaneous splenic rupture (SSR) is a rare phenomenon where the spleen ruptures without associated trauma. SSR can lead to an intra-abdominal haemorrhage and an acute abdomen that can be life threatening.

Case presentation

In this article, we present the case of an 81-year-old woman with chronic lymphocytic leukaemia who presented to the emergency department with severe abdominal pain.

Clinical discussion

In order to stabilize the patient, while awaiting elective surgery, we managed the rupture with splenic embolization and we reviewed the literature related to the treatments of SSR especially, by arterial splenic embolization.

Conclusion

Splenic embolization is a safe treatment option, that allows a rapid stabilization and has the advantage of both, splenectomy and conservative treatment.

Splenic rupture caused by pancreatic pseudocyst successfully treated by endoscopic ultrasound-guided drainage

A 43-year-old man was admitted to a local hospital because of acute left abdominal pain. Chronic alcoholic pancreatitis and a 10-cm pancreatic pseudocyst in the tail of the pancreas had been found 5 years previously. He had not stopped drinking alcohol since then. On admission, laboratory tests revealed severe anemia, and contrast-enhanced computed tomography showed extravasation in the pancreatic pseudocyst. The spleen was retracted by the pancreatic pseudocyst, and its configuration was indistinct. The patient was diagnosed with acute bleeding within the pancreatic pseudocyst and splenic rupture. He was transferred to our university hospital on an emergency basis. Abdominal angiography of the splenic artery was immediately performed, but the bleeding point was not found. Although the bleeding stopped spontaneously, an infection of the pancreatic pseudocyst and a splenic hematoma subsequently developed. Endoscopic ultrasound-guided pseudocyst drainage was performed. The infection improved after the drainage, and the size of the pancreatic pseudocyst and splenic hematoma decreased. Five months later, the pancreatic pseudocyst had almost disappeared, and the splenic hematoma was even smaller. We herein report a rare case of splenic rupture caused by a pancreatic pseudocyst. Although the patient's condition became complicated by severe infection, treatment by endoscopic ultrasound-guided drainage was successful.