Spomtaenous Splenic rupture Precipitated by Cough

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Slide 1 :

Spontaneous splenic rupture precipitated by cough Edgard Wehbe, MD. April 2008 University of Kansas School of Medicine-Wichita

Slide 2 :

Clinical Presentation A 61-year-old male patient presented to the ED: LUQ pain radiating to his chest/left shoulder. Nausea, dizziness. SOA. ROS: Chronic cough.

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Clinical Presentation PMH/PSH: CAD COPD CHF GERD CVA Medication: Aspirin Clopidogrel Losartan Metoprolol Simvastatin Furosemide

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Clinical Presentation Physical exam: VS: BP: 74/57 HR: 82 T: 97.6 O2 sat: 94% General: AAO, mild distress. HEENT: dry mucous membrane Lungs: CTAB CV: RRR, no murmur. Abdomen: BS+, diffusely tender, rebound tenderness and guarding in the LUQ. Ext: cool, no edema.

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Clinical Presentation Workup: LAB: HGB: 11.4 WBC: 13.5 ( N:84%, BAND: 1%) NA: 132 Creat: 1.2. PTT: 28.6 INR: 1.02 Chest X ray: Cardiomegaly, vascular congestion, small left pleural effusion IV Fluid started.

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Clinical Presentation CT scan of the abdomen: Large soft tissue mass involving the left upper abdominal quadrant with areas of both decreased and increased attenuation. This most likely represents splenic rupture with both subcapsular hematoma formation, as well as bleeding beyond the capsule

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Clinical Presentation Surgery: >2L hemoperitoneum, avulsed capsule of spleen. Splenectomy. Pathology: Splenic rupture, with focal subcapsular hematoma. No significant chronic or acute inflammation, well-formed epithelioid granulomas, atypical lymphoid hyperplasia, dysplasia, or neoplasias are identified

Slide 8 :

Spontaneous Splenic Rupture Review of the literature

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Spontaneous splenic rupture Spontaneous splenic rupture is rare with an incidence of 0.1-0.5%. Still a subject of debate to consider “spontaneous rupture of the spleen “as distinct clinicopathologic entity. Thomas WEG. Apparent spontaneous rupture of the spleen. Br Med J 1978; i:409–410 Andrews DF, Hernandez R, Gafron W, et al: Pathologic rupture of the spleen in non Hodgkin’s lymphoma. Arch Intern Med 1980; 140:119-120

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Spontaneous splenic rupture Atkinson in 1874: first case described. Widman in 1927: first time to use the term SSR. Knoblich in 1966: “spontaneous” be replaced by “pathologic” in atraumatic rupture of the diseased spleen.

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Spontaneous splenic rupture Atraumatic rupture of the spleen Spntaneous Normal spleen Pathologic: diseaded spleen. Debnath and Valerio Wright and Prigot: “There is no such clinical entity as spontaneous rupture of the normal spleen.” Johnson: careful questioning of the patient and relatives will always elicit a history of injury.

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Spontaneous splenic rupture Criteria to diagnose SSR: There should be no history of trauma or of unusual effort which conceivably could injure the spleen. There should be no evidence of disease in organs other than the spleen which is known to affect the spleen adversely and thereby could cause it to rupture. There should be no evidence of perisplenic adhesions or scarring of the spleen that suggests that it had been traumatized or had ruptured previously. Other than the findings of hemorrhage and rupture, the spleen should be normal on both gross inspection and histologic examinations. Full virological studies of acute phase and convalescent sera should show no significant rise in viral antibody titers suggesting recent viral infection of types associated with splenic involvement. Orloff MJ, Peskin GW. Spontaneous rupture of the normal spleen: a surgical enigma. Int Abstr Surg 1958; 106:90

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Spontaneous splenic rupture The true etiology is still unknown and all the theories are subject of debate: Localized involvement of the spleen with a pathologic process, which upon rupture all evidence of pathologic changes are destroyed. Reflex spasm of splenic vein causing acute splenic congestion. Portal venous congestion with chronic splenic congestion. Abnormally mobile spleen that undergoes recurrent torsions and the resultant congestion leads to rupture. Rupture of a degenerative or aneurysmal splenic artery. Forgotten or unnoticed trauma. Sudden increase in abdominal pressure leads to rupture (i.e. a heavy meal, defecation, lifting, sexual intercourse, cough, vomiting). Surgery On-Line 2005

Slide 14 :

Spontaneous splenic rupture It has been postulated that the incidence of rupture correlate with the size of the spleen. In a retrospective study by Bauer and Haskins the percentage of normal sized spleen that ruptured was up to 48%.

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