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Spontaneous Rupture of Spleen - A Rare Case Report

Article Information

Manohar Kachare1*, Naila Azmi2

1Professor and Head, Department of Radiodiagnosis, Government Medical College Miraj, Maharashtra, India

2Department of Radiodiagnosis, Government Medical College Miraj, Maharashtra, India

*Corresponding Author: Manohar Kachare, Professor and Head, Department of Radiodiagnosis, Government Medical College Miraj, Pandharpur Road, Maji Sainik Vasahat, Miraj, Maharashtra - 416410, India

Received: 11 May 2021; Accepted: 25 August 2021; Published: 01 October 2021

Citation: Manohar Kachare, Naila Azmi. Spontaneous Rupture of Spleen - A Rare Case Report. Journal of Radiology and Clinical Imaging 4 (2021): 125-131.

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Abstract

Spleen is highly vascular organ & non traumatic spleen rupture is rare association. Non traumatic splenic rupture has pathologic association with few diseases which cause splenomegaly followed by rupture. This case report describes the first and rare incidence of non-traumatic splenic rupture in a case of concealed perforated jejunal diverticulitis.

Keywords

Spleen; Rupture; Spontaneous; Diverticulitis; Splenectomy

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Article Details

1. Introduction

Spleen being extremely vascular structure, splenic rupture is a fatal medical emergency [1, 2]. Although traumatic association is most common, rupture due to underlying malignancy or infection of Infectious mononucleosis, malaria besides chronic haematological abnormality which can cause splenic enlargement leading to thinning of cortex & hence making susceptible to even minor trauma is not uncommon [3]. The spontaneous rupture of spleen is rare incidence. This case is being reported from a tropical country with spontaneous spleen rupture being not attributable to malaria or infectious mononucleosis. Between 1917 to 1948 number of 64 cases and between 1950 to 2011 approximately 613 cases of spontaneous spleen rupture are well documented [3, 4].

2. Case History

A 60-year-old man admitted in hospital with a complaint of pain in left paraumbilical region & fever for 1 week. On USG abdomen there was collection in left paracolic gutter in paraumbilical region. CECT imaging had revealed – diffusely enlarged pancreas with inhomogeneous hypoen-hancement with mild peripancreatic peritoneal reflection thickening. Duodenum had nodular thickening in D2 & D3 segments. There were multiple jejunal outpouchings present from mesenteric border of jejunal loops predominantly in left lumbar & iliac regions. There was localised perforation of few of diverticula secondary to a possible background diverticulitis. There was clustering of small bowels in left half of abdomen associated with moderate localised inflam-matory changes. The diagnosis of localised perforated peri-tonitis was ascertained. There was a small rim enhancing encysted fluid collection. Free fluid collection was noted extending into left paracolic gutter reaching to left iliac fossa. There was reactive inflammation of descending colon & proximal sigmoid colon associated with congested vessels around. Imaging findings of background jejunal diverticulosis with secondary diverticulitis were seen. Localised concealed perforation of the few of the recently infla-med diverticula with resultant localised peritonitis & subacute interstitial oedematous pancreatitis was ascertained.

Under USG guidance approximately 60 cc of pus was drained from left paracolic gutter collection and patient was treated with antibiotics and anti-inflammatory for 1 week and was discharged. After 13 days patient again came with acute pain in abdomen in left hypochondriac region in afternoon. Pain had suddenly aggravated overnight. As the patient was deteriorated his abdomen was again investigated with CECT which revealed spleen of size 197 × 98 X 156 mm in mixed density, non-enhancing lesion noted in left subdiaphragmatic space in splenic fossa in subcapsular region of the spleen causing medial displacement & compr-ession of residual, normally enhancing spleen. Jejunal loops were thickened persistently although the adjacent collection was merely of 30 X 15 mm with thick enhancing wall. The imaging findings were consistent with spleen rupture. Patient was hence shifted to tertiary care centre. Hemogram revealed decreased haemoglobin to 7 gm% & leucocytosis (TLC=21000); rest of the haematological, Serum lipase was found to be 1.4 times the upper normal limit; rest of the biochemical as well as microbiological investigations were normal. Emergency splenectomy was done. Intra-operative findings showed rupture of spleen with large hematoma. The splenic vessels at hilum were normal. The enlarged ruptured spleen measured 13 × 8 × 4 cm with congestion and focal capsular tear was seen. Specimen was given for histopathological examination which revealed congested sinusoids, subcapsular haemorrhage without any other specific lesion. Splenectomy was uneventful. In between the two episode of symptoms patient had no history of trauma or any surgical intervention. Thus this case can be considered as a spontaneous rupture of spleen.

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Figure 1: Perforated Jejunal diverticulum with collection and air noted within.

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Figure 2: Axial CECT showing spleen with coronal & sagittal reformats 14 days prior to spontaneous rupture of spleen.

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Figure 3: Post contrast study showing ruptured spleen large intrasplenic hematoma, causing a mass effect, and extensive intraperitoneal free fluid.

3. Discussion

Spleen is very vascular & functionally diverse organ meant for haematopoiesis & immunosurveillance while making interactions between the circulatory, reticuloendothelial, and immune systems [5, 6]. Traumatic spleen rupture has been well documented. Spontaneous splenic rupture is rare and predisposing conditions include haematological diseases with splenic infiltration, splenic infarcts, male gender, massive splenomegaly, angiosarcoma of the spleen & certain infections more commonly like EBV & malaria. Between 1917 to 1948 number of 64 cases and between 1950 to 2011 approximately 613 cases of spontaneous spleen rupture are well documented [3, 4].

Orloff and Peskin recognized four-step criteria for the diagnosis of spontaneous rupture consisting of 1. no history of trauma, 2. no perisplenic adhesions which support previous trauma, 3. no disease affecting the spleen, and 4. on gross and histologic examinations there is presence of a normal spleen [7]. Crate and Payne then added a fifth criterion i.e.: Full virologic studies of acute phase and convalescent sera should show no significant rise in antibody titres which suggests recent viral infection of types known to have splenic involvement [8]. The number of cases which fulfil Orloff and Peskin’s criterion is by far less. In a systemic review by F Kris Aubrey and Nicholas Sowers of 613 cases of non-traumatic spleen rupture 18% have been attributed to medical procedures while 23% being attributed to infectious disease [3]. Our case fulfilled all Orloff and Peskin’s criterion hence is reported as spontaneous spleen rupture case. Causes of Spontaneous splenic rupture is varied and although not complete the list is comprehensive [3, 9] [Table 1].

Cause

Disease

Infections

Infectious mononucleosis

HIV

Hepatitis A/B/C

Rubella

Varicella

Legionellosis

Bartenellosis

Infective endocarditis (Staphylococcus, Streptococcus, Clostridium, Actinomycosis, Pseudomonas among the top causes)

Enteric fever

Tuberculosis

Syphilis

Malaria

Kalaazar

Hematologic and neoplastic causes

Haemophilia

Anticoagulation

Hemolytic anemia

Angiosarcoma

Choriocarcinoma

Myeloid metaplasia/fibrosis

Lymphoma and leukemia

Multiple myeloma

Polycythemia vera

Inflammatory

Crohn’s disease

Pancreatitis

Polyarteritis nodosa

Lupus erythematosus

Rheumatoid arthritis

Infiltrative causes

Amyloidosis

Felty’s syndrome

Sarcoidosis

Iatrogenic

Anticoagulants - Warfarin / Heparin

Granulocyte colony stimulating factor

Therapeutic thrombolysis

Dialysis

Lithotripsy

Primary splenic disorders

Splenic cyst

Splenic angiomatosis

Splenic peliosis

Splenic infarctions or venous thrombosis

Portal hypertension

Congenital malposition (i.e. short splenic pedicle)

Internal trauma

Pregnancy

Cough / Vomiting

Table 1: Causes of spontaneous rupture of spleen.

The possible mechanism of spleen rupture is hypothesised as -

References

  1. Redmond HP, Redmond JM, Rooney BP, et al. Surgical anatomy of the human spleen. British journal of surgery 76 (1989): 198-201.
  2. Rhee SJ, Sheena Y, Imber C. Spontaneous rupture of the spleen: a rare but important differential of an acute abdomen. The American journal of emergency medicine 26 (2008): 733-e5.
  3. Aubrey-Bassler FK, Sowers N. 613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review. BMC emergency medicine 12 (2012): 11.
  4. Hershey FB, Lubitz JM. Spontaneous rupture of the malarial spleen: case report and analysis of 64 reported cases. Annals of surgery 127 (1948): 40.
  5. De Porto AP, Lammers AJ, Bennink RJ, et al. Assessment of splenic function. European journal of clinical microbiology & infectious diseases 29 (2010): 1465-1473.
  6. Chadburn A. The spleen: anatomy and anatomical function. InSeminars in hematology 37 (2000): 13-21.
  7. Orloff M, Peskin G. Spontaneous rupture of the normal spleen; a surgical enigma. InInternational abstracts of surgery 106 (1958).
  8. Crate ID, Payne MJ. Is the diagnosis of spontaneous rupture of a normal spleen valid?. Journal of the Royal Army Medical Corps 137 (1991): 50-51.
  9. Amonkar SJ, Kumar EN. Spontaneous rupture of the spleen: three case reports and causative processes for the radiologist to consider. The British journal of radiology 82 (2009): e111-e113.
  10. Rice JP, Sutter CM. Spontaneous splenic rupture in an active duty Marine upon return from Iraq: a case report. Journal of medical case reports 4 (2010): 353.
  11. Leighton WE. Spontaneous rupture of the malarial spleen, with abstract of cases reported between 1842 and 1921. Annals of surgery 74 (1921): 13.
  12. Schattner A, Meital A, Mavor E. Red-flag syncope: spontaneous splenic rupture. The American journal of medicine 127 (2014): 501-502.
  13. Debnath D, Valerio D. Atraumatic rupture of the spleen in adults. Journal of the Royal College of Surgeons of Edinburgh 47 (2002): 437-445.
  14. Toubia NT, Tawk MM, Potts RM, et al. Cough and spontaneous rupture of a normal spleen. Chest 128 (2005): 1884-1886.
  15. King H, Shumacker Jr HB. Splenic studies: I. Susceptibility to infection after splenectomy performed in infancy. Annals of surgery 136 (1952): 239.
  16. Coccolini F, Montori G, Catena F, et al. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World Journal of Emergency Surgery 12 (2017): 40.

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