Figure 1: Axial (A) and coronal (B) CT-scan showing subcapsular
hematoma (empty arrows), diffuse hemoperitoneum (arrow heads) and
residue or the ruptured spleen (full arrows).
A massive blood transfusion and an emergency laparotomy for splenectomy
were performed. In total, the patient received seven packed red blood
cells, six fresh frozen plasma and one pool of platelets. During the
laparotomy, the surgeon sucked out more than two liters of fresh blood
and clots. Hemostasis was rapidly obtained by ligation of the splenic
vessels and total removal of the spleen that had a large parenchymal
laceration. 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. He
remained in the surgical ward for another week before going home.
Rivaroxaban has been permanently discontinued. The vaccines
against encapsulated organisms have been administered. A holter monitor
was performed by the cardiologist at 1 and 4 months after surgery and
showed no recurrence of rhythm disorders. 10 months later, the patient
is morally and physically well and has completely resumed his daily
activities.
Discussion:
The abdominal trauma is the first and well-known cause of splenic
rupture [1]. Because ASR is rare, its diagnosis is often delayed,
and mortality is estimated at 12,2% [2]. Mortality is increased in
cases of delayed diagnosis, splenomegaly, underlying neoplastic disease
and an age above 40 years [2] [4].
The ASR can be classified into 2 categories: a pathological rupture (ASR
occurred on a diseased spleen) and idiopathic rupture (ASR occurred on a
healthy spleen), also called “spontaneous rupture” [6]. According
to Orloff and Peskin, an idiopathic rupture must meet 4 criteria: no
trauma history; no other diseased organs that can cause the splenic
rupture; no peri-splenic adhesions or pre-existing scars; a
macroscopically and histologically normal spleen [7]. Later, Crate
and Payne proposed a 5th criterion: no increase in
serological antibody titer in the acute and convalescent phase
suggesting a recent viral infection known to be involved in splenic
rupture [8].
In a systematic review, F Kris Aubrey-Bassler and Nicholas Sowers showed
that most of the time spleen rupture was the first symptom of an unknown
underlying disease. Indeed, due to its important vascularization, if the
spleen is afflicted by disease, the risk of rupture after a trivial
stress is increased [9]. In the literature, many authors misuse the
word ”spontaneous” instead of the term ”pathological” or ”atraumatic”
[3]. “True spontaneous” splenic rupture is very rare. In this same
review, 47 cases out of 613 (7,6%) were associated with drugs, 21 of
which were associated with anticoagulants [3]. In another review, P.
Renzulli et al. identified 845 patients with ASR and divided them into 6
etiological groups (Table 2). They showed a ratio male : female of 2 : 1
and a mean age of 45. Of the 845 cases, 67 were associated with drugs,
22 of which were anticoagulants. Only 59 patients (7%) had a spleen
described as normal and no causal factor was found. 465 patients (55%)
had splenomegaly. 84% underwent total splenectomy as first-line
treatment. 14.9% of the patients with a conservative treatment had
splenectomy for rebleeding. The percentage of surgical management is
much higher than in the case of traumatic rupture. This is explained by
a higher rate of conservative treatment failure associated with an
abnormal spleen and by an older population [4].