A rare cause of acute abdominal pain

A 54-year-old postmenopausal woman presented to the ED complaining of progressively worsening abdominal pain for the past 12 hours. She stated the pain began abruptly after she awoke and originated in the epigastric area. The pain has since migrated to her left upper quadrant and radiates into her back.

The patient has a history of multiple sclerosis treated with teriflunomide and baclofen. Her past surgical history includes tubal ligation, tonsillectomy, and knee arthroscopy, all more than 10 years ago. She smokes 3 to 4 cigarettes per day but denies chronic alcohol use. She denies associated nausea, vomiting, fever, change in bowel habits, recent abdominal or back trauma, recent viral illness, or chronic use of nonsteroidal anti-inflammatory drugs.

The patient's initial vital signs were BP, 90/80 mm Hg; heart rate, 87 beats/minute; respirations, 19; SpO₂, 99% on room air; and temperature, 97° F (36° C). She was awake, alert, and oriented but appeared uncomfortable. Her lungs were clear in all fields. Her cardiac rate and rhythm were normal. Her abdomen was flat, diffusely tender with superficial and deep palpation, and maximally tender in the left upper quadrant, with guarding, rebound tenderness, and peritoneal signs.

The patient's complete blood cell count was abnormal with a slightly decreased red blood cell count, hemoglobin of 11.2 g/dL (normal range, 11.8 to 15 g/dL), hematocrit of 33.9 g/dL (normal range, 36 to 47 g/dL), white blood cell count of 11,100 cells/mm 3 (normal range, 4,100 to 10,700 cells/mm 3), and platelet count of 175,000 cells/mm 3 (normal range, 150,000 to 400,000 cells/mm 3). Her serum lactic acid and lipase were within normal limits. A complete metabolic panel was within normal limits.

A CT scan of the abdomen (Figure 1) revealed moderate amounts of fluid within the abdomen and pelvis with heterogeneous density of the spleen. CT angiogram of the aorta did not show any evidence of aneurysm or dissection. CT scan of the chest was negative.

Upon evaluation by the acute care surgical team, the patient was found to be in hemorrhagic shock secondary to a spontaneous splenic laceration. Although uncommon, splenic lacerations can occur in the absence of trauma and require emergent abdominal CT scanning and surgical intervention for definitive treatment. The heterogeneous density found on CT scan, physical examination positive for peritoneal signs, and hemodynamic instability were the clues pointing to the diagnosis in this patient.

Perforated peptic ulcer and diverticulitis with perforation present with similar symptoms to spontaneous splenic laceration, including exquisite abdominal tenderness, rebound tenderness, guarding, and peritoneal signs. Patients with perforated peptic ulcer may have a history of chronic nonsteroidal anti-inflammatory drug use, and those with diverticulitis with perforation typically have pain localized to the left lower abdominal quadrant. These diagnoses were ruled out because the patient's CT scan showed heterogenous density around the spleen, indicating blood; patients with the other two diagnoses will have free air in the abdomen, indicating perforation.

Most splenic lacerations occur due to blunt or penetrating injury. A systematic review of literature of 845 patients with atraumatic splenic avulsions found that more than 75% of atraumatic splenic avulsions were caused by neoplasm, infection with infectious mononucleosis, or inflammatory diseases; atraumatic idiopathic splenic lacerations occurred in only 7% of reviewed patients.1 Given this patient's negative pathology report and past history lacking recent viral illness or inflammatory disease, the cause of her spontaneous splenic avulsion was likely idiopathic.

The American Association for the Surgery of Trauma grades splenic lacerations on a scale of 1 to 5.2 Hemodynamically stable patients with lower-graded spleen lacerations may be managed conservatively with observation, serial hemoglobin and hematocrit levels, serial abdominal examinations, or localized splenic embolization by interventional radiology.3 Conservative approaches in hemodynamically stable patients prevent exposure to surgical complications and preserve splenic tissue. More aggressive surgical intervention was needed for this patient, who presented in hemorrhagic shock.

The patient was taken emergently to the OR, where an exploratory laparotomy revealed a splenic laceration with complete splenic capsular avulsion and active hemorrhage with an estimated blood loss of 1.5 L. A total splenectomy was performed. Intraoperatively, the patient received 2 units of packed red blood cells and 2 units of fresh frozen plasma to correct her acute blood loss.

Postoperatively, the patient was transferred to the surgical ICU, where samples were drawn for serial hemoglobin and hematocrit levels. Once her hemoglobin had stabilized, she was moved to the surgical trauma unit. Serial abdominal examinations revealed a resolution of her abdominal pain. On postoperative day 3, she was transitioned to a clear liquid diet and eventually to a regular diet.

During her hospitalization, she received postsplenectomy vaccinations including pneumococcal, meningococcal, and haemophilus B vaccinations. Her spleen was sent for pathologic evaluation and was negative for tuberculoid granulomata or occult neoplasia. She was discharged home after 5 days with strict instructions to avoid contact sports, heavy lifting, and strenuous activity.

1. Renzulli P, Hostettler A, Schoepfer AM, et al. Systematic review of atraumatic splenic rupture. Br J Surg. 2009;96(10):1114–1121. Ovid Full Text Bibliographic Links [Context Link]

2. Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008;207(5):646–655. Bibliographic Links [Context Link]