Table 3 provides interesting informations:
- Several authors, such as Gonzva, use the term ”spontaneous splenic
rupture” in the title of their article without mentioning whether they
had previously looked for diseases affecting the spleen
[19][20][21][22][23][24][25][26][27].
Spontaneous splenic rupture in the literature is more frequent than in
real life due to the abuse of language.
- The population with ruptured spleen associated with DOAC is much older
than the all-cause population. Their respective mean ages are 72.2
versus 44.
- The ratio male : female is 1,33 : 1 if we include our own case.
- There are many more cases described with rivaroxaban and apixaban. We
did not find any cases described in the literature with edoxaban and
betrixaban
- The failure rate of non-operative treatment by embolization of the
splenic artery is 71%.
In our patient, the symptomatology was unclear, the pain was crampy and
diffuse without muscle guarding. Given his recent history of atrial
fibrillation ablation, we wanted to exclude a tamponade or another
cardiac problem first. Moreover, the biology and arterial blood gases
were reassuring on admission. A posteriori we hypothesized that the
patient first injured his spleen consecutive to the multiple efforts of
defecation. Then rivaroxaban led to a painful subcapsular hematoma that
eventually tore the capsule and parenchyma. Our diagnosis was delayed.
Moreover, the patient being on bisoprolol and amiodarone never presented
with tachycardia. We did not make the diagnosis in the cardiology unit
with the E-FAST because the computed tomography scan of the abdomen was
directly available at a standard procedure in our institution. Splenic
rupture was most likely spontaneous based of the lack of evidence for
neoplastic, inflammatory or infectious etiologies. Moreover, the
anatomopathological examination of the spleen was macro and
microscopically normal.
Conclusion
We will remember that the
symptomatology of a ruptured spleen can be very atypical. The diagnosis
can be difficult. Facing a patient presenting with unspecific abdominal
pain and hypotension, an E-FAST should be performed. Even though
ruptured spleen remains a diagnosis of exclusion, it can be favoured
using DOAC. Often, splenic rupture is associated with an underlying
disease and should be defined as ”atraumatic” and not ”spontaneous”.
Splenectomy remains the gold standard for an unstable patient.
Patient perspective
The patient does not remember the hours before the surgery and being
taken to the operating room. With his median laparotomy and his
constipation problems in spite of an adapted diet and treatment, he is
anxious when he has to go to the stool even 10 months later. For the
rest, he is happy to have been able to resume his daily activities as
usual.
Consent
The patient has given consent for his medical data and images to be
described in this article.
Conflict of interest disclosure
Non declared.
Funding statement
none
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