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].