Atraumatic splenic rupture in a patient treated with rivaroxaban: a case
report and a narrative review.
Authors: Labaki M.-L.*; De Kock M.**
*Department of Intensive Care, Centre Hospitalier de Wallonie Picarde
(CHwapi), Tournai, Belgium. E-mail:labaki.ml@gmail.com
**Department of Intensive Care, Centre Hospitalier de Wallonie Picarde
(CHwapi), Tournai, Belgium. E-mail:marcdekock1888@gmail.com
Abstract:
Introduction : Atraumatic splenic rupture (ASR) is rare, mostly
associated with neoplastic, infectious and inflammatory diseases. ASR
related to drug treatment is infrequent. In this case report we
highlight an unusual complication of the direct oral anticoagulant
rivaroxaban.
Case presentation : A 64-year-old male patient was admitted in the
emergency department for lipothymic illness on diffuse abdominal cramps.
There is no history of recent trauma. The clinical examination showed
hemodynamic instability with moderate response to filling and a mild
abdominal discomfort on palpation. His medical history included chronic
hypertension, chronic constipation and a recent atrial flutter ablation.
He was taking amiodarone, bisoprolol, atorvastatin, and rivaroxaban 20
mg. The diagnosis of splenic rupture was made several hours later with
an abdominal CT scan with contrast injection. A massive blood
transfusion and an emergency laparotomy for splenectomy were performed.
The anatomopathological analysis did not reveal any cause of neoplastic,
inflammatory or infectious cause. The patient was successfully
discharged from intensive care unit 3 days later.
Conclusion : Clinicians must remember the potential ASR as
complication due to direct oral anticoagulants when they are confronted
to a patient with abdominal tenderness and hemodynamical instability.
Unfortunately, the clinical presentation is not always typical of a
ruptured spleen. Delayed diagnosis can be life-threatening and fatal.
Splenectomy by laparotomy remain the best therapeutic option in case of
splenic rupture in unstable patients on direct oral anticoagulants.
Keywords: atraumatic splenic rupture, rivaroxaban, direct oral
anticoagulant, spontaneous splenic rupture, apixaban, dabigatran,
betrixaban, edoxaban.
Introduction:
The abdominal trauma is a well-known cause of splenic rupture [1].
The major problem in atraumatic splenic rupture (ASR) is the missed or
delayed diagnosis and consequently, delayed management leading to fatal
outcome. In case of ASR, the mortality rate is around 12,2%. [2]
Several systematic reviews of the literature reported that the main
etiologies are infectious, neoplastic and inflammatory. The drug-related
cause is even more rare [3][4]. Since the emergence of direct
oral anticoagulants (DOAC) at the beginning of the 21st century,
physicians are increasingly confronted with their adverse effects and
complications. In this article we describe a case of ASR in a patient
treated with rivaroxaban according to CARE guidelines [5]. Then, we
made a narrative review of the literature by searching until June 2022
other similar cases in the Pubmed and Google scholardatabases with relevant keywords. Only cases written in French and
English were retained. We compared them and looked for factors promoting
splenic rupture and bleeding in patients taking rivaroxaban and other
DOAC.
Case presentation:
A 64-years-old male patient was admitted in the emergency department for
lipothymic illness on diffuse abdominal cramps. His medical history
included chronic hypertension, chronic constipation and an atrial
flutter ablation 6 days before. He was taking amiodarone, bisoprolol,
atorvastatin, and rivaroxaban 20 mg. There is no history of trauma or
infections in the previous months. Moreover, the patient has limited
contact with the outside world because of the covid-19 pandemic. His
parameters were a blood pressure at 85/55 mmHg, a sinusal cardiac rate
at 76 beats per minute, an oxygen saturation level of 99% on room air
and a normal body temperature. The physical examination highlighted a
normal cardiopulmonary auscultation, a mild diffuse abdominal tenderness
at the palpation without guarding or irradiation.
He underwent several complementary tests. His blood tests (hemoglobin,
white blood cells, coagulation, ionogram, liver and kidney functions)
came back normal (Table 1). There was no increase in lactate on the
arterial blood gases. The urine spot is without particularity. The PCR
test for covid 19 is negative. The electrocardiogram shows a sinusal
rythm with a frequence around 70 beats per minute and no repolarisation
troubles.