Table 3 provides interesting informations:
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
References
[1] Shamim SM, Razzak JA, Umer SM, Chawla T. Splenic injury after blunt abdominal trauma: an unusual presentation. J Emerg Med . 2011;41(5):489-491.
[2] Pinar Cigdem Kocael, Osman Simsek, Ismail Ahmet Bilgin, Onur Tutar, Kaya Saribeyoglu, Salih Pekmezci, Ertugrul Goksoy; Characteristics of Patients With Spontaneous Splenic Rupture. Int Surg 1 November 2014; 99 (6): 714–718
[3] Aubrey-Bassler FK, Sowers N. 613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review. BMC Emerg Med . 2012;12:11.
[4] Renzulli P, Hostettler A, Schoepfer AM, Gloor B, Candinas D. Systematic review of atraumatic splenic rupture. Br J Surg. 2009 Oct;96(10):1114-21
[5] Riley, D. S., Barber, M. S., Kienle, G. S., Aronson, J. K., von Schoen-Angerer, T., Tugwell, P., Kiene, H., Helfand, M., Altman, D. G., Sox, H., Werthmann, P. G., Moher, D., Rison, R. A., Shamseer, L., Koch, C. A., Sun, G. H., Hanaway, P., Sudak, N. L., Kaszkin-Bettag, M., Carpenter, J. E., … Gagnier, J. J. (2017). CARE guidelines for case reports: explanation and elaboration document. Journal of clinical epidemiology , 89 , 218–235.
[6] Debnath D, Valerio D. Atraumatic rupture of the spleen in adults. J R Coll Surg Edinb . 2002;47(1):437-445.
[7] Dunphy L, Abbas SH, Patel A, Tebala G. Spontaneous splenic rupture: a rare first presentation of diffuse large B cell lymphoma.BMJ Case Rep . 2019;12(8)
[8] Crate ID, Payne MJ. Is the diagnosis of spontaneous rupture of a normal spleen valid?. J R Army Med Corps . 1991;137(1):50-51.
[9] Amonkar SJ, Kumar EN. Spontaneous rupture of the spleen: three case reports and causative processes for the radiologist to consider.Br J Radiol . 2009;82(978):e111-e113.
[10] Deol D, Wu H, Lasso-Pirot A, Robinett KS, Diaz-Abad M. Atraumatic Splenic Rupture Associated with Influenza A (H1N1) Pneumonia: Case Report and Review of the Literature. Case Rep Med . 2021;2021:6516064
[11] Wehbe E, Raffi S, Osborne D. Spontaneous splenic rupture precipitated by cough: a case report and a review of the literature. Scand J Gastroenterol . 2008;43(5):634-637.
[12] Sikka R. Unsuspected internal organ traumatic injuries. Emerg Med Clin North Am. 2004 Nov;22(4):1067-80
[13] Gedik E, Girgin S, Aldemir M, Keles C, Tuncer MC, Aktas A. Non-traumatic splenic rupture: report of seven cases and review of the literature. World J Gastroenterol . 2008;14(43):6711-6716
[14] Lieberman ME, Levitt MA. Spontaneous rupture of the spleen: a case report and literature review. Am J Emerg Med . 1989;7(1):28-31.
[15] Coccolini, F., Montori, G., Catena, F., Kluger, Y., Biffl, W., Moore, E. E., … & Ansaloni, L. (2017). Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World Journal of Emergency Surgery12 (1), 1-26.
[16] Liew A, O’Donnell M, Douketis J. Comparing mortality in patients with atrial fibrillation who are receiving a direct-acting oral anticoagulant or warfarin: a meta-analysis of randomized trials. J Thromb Haemost . 2014;12(9):1419-1424.
[17] Hellwig T, Gulseth M. Pharmacokinetic and pharmacodynamic drug interactions with new oral anticoagulants: what do they mean for patients with atrial fibrillation?. Ann Pharmacother . 2013;47(11):1478-1487.
[18] Roberti R, Iannone LF, Palleria C, et al. Direct Oral Anticoagulants: From Randomized Clinical Trials to Real-World Clinical Practice. Front Pharmacol . 2021;12:684638.
[19] Gonzva J, Patricelli R, Lignac D. Spontaneus splenic rupture in a patient treated with rivaroxaban. Am J Emerg Med . 2014;32(8):950.e3. doi:10.1016/j.ajem.2014.01.049
[20] Hattab, Yousef A., Daniel Speredelozzi, and Omar Bajwa. ”C52 ILLUSTRATIVE DISEASE PRESENTATIONS IN CRITICAL CARE I: Rivaroxaban Causing Spontanuos Splenic Rupture.” American Journal of Respiratory and Critical Care Medicine  191 (2015): 1.
[21] Naseem, Zainab, Muslim Mustaev, and Boris Strekozov. ”Spontaneous splenic rupture secondary to rivaroxaban: Rare but raising.” IJSM  2 (2016): 134-6.
[22] Amin, Arpit, et al. ”Hemorrhagic shock from spontaneous splenic rupture requiring open splenectomy in a patient taking rivaroxaban.” The American Surgeon  82.2 (2016): E54.
[23] Nagaraja V, Cranney G, Kushwaha V. Spontaneous splenic rupture due to rivaroxaban. BMJ Case Rep . 2018;2018:bcr2017223237.
[23] Pietsch, Ekkehard. ”Spontaneous Splenic Rupture Under Xarelto.” EC Gastroenterology and Digestive System  8 (2021).
[24] Moore CH, Snashall J, Boniface K, Scott J. Spontaneous splenic hemorrhage after initiation of dabigatran (Pradaxa) for atrial fibrillation. Am J Emerg Med . 2012;30(9):2082.e1-2082.e20822.
[25] Lowry, Lacy E, and Jonathan A Goldner. “Spontaneous splenic rupture associated with apixaban: a case report.” Journal of medical case reports  vol. 10,1 217. 9 Aug. 2016.
[26] Abdelhady, A et al. “Apixaban-Associated Spontaneous Splenic Rupture-A Case Report.” Irish medical journal  vol. 111,7 792. 13 Aug. 2018
[27] Janke, Alexander et al. “Spontaneous splenic hemorrhage in a patient on apixiban.” The American journal of emergency medicine  vol. 38,5 (2020): 1044.e1-1044.e2.
[28] Basnet, Sijan et al. “Atraumatic splenic rupture associated with apixaban.” SAGE open medical case reports  vol. 7 2050313X19832490. 21 Feb. 2019
[29] Yau, Ho-Cing Victor et al. “Atraumatic splenic rupture in a patient treated with apixaban: A case report.” International journal of surgery case reports  vol. 71 (2020): 270-273.
[30] Natarajan, Piruthiviraj et al. “Atraumatic Splenic Rupture in a Patient on Apixaban and Dual Antiplatelet Therapy.” Journal of investigative medicine high impact case reports  vol. 9 (2021): 23247096211026492.