Spontaneous Splenic Rupture · pathology – “atraumatic pathological rupture” 7% there is no...

V. Roudnitsky MDLICH

2/3/2011

Spontaneous Splenic Rupture

www.downstatesurgery.org

53 yo F with PMH of mild HTN Home meds Norvasc, Plavix Presented in ER 1/14/11 with c/o left

chest/shoulder pain , epigastric pain for 6-7 hrs Pain started gradually, was constant, cramping,

severety 9/10 , accompanies by nausea, dizziness and mild SOB

Family Hx – CAD Patient is active tobacco smoker VS HR 81, BP 90/65 118/80, RR 20, Sat 100%,

Temp 98.4 PE – unremarkable beside mild epigastric

tenderness

Labs: BMP/LFTs/Coags - WNL CBC 11.5/11.6/34.1/275 Troponin WNL

EKG – no acute ischemic changes Patient was admitted to Telemetry to r/o ACS

Case Presentation DOA #1-2 :

serial Troponin/ECG were negative VS: persistent HR 100-120, SBP low 100, sat 98-100%.

DOA #3 Patient had c/o SOB , Sat 92-95%, HR 100- 120 Chest CTA to R/o PE

DOA 1 2 3Hg 11.6 9.9 7.7Hct 34.1 29.5 23.4

1/16/2011

CTA Chest

No evidence of PE. Small hyperdense ascites, possibly hemorrhagi

c. Partially visualized spleen with heterogeneous

attenuation and irregular contour

DOA 1 2 3 4

Hg 11.6 9.9 7.7 7.6

Hct 34.1 29.5 23.4 22.8

DOA # 4

CT abdomen obtained

Surgical consult called.

1/17/2011

DOA # 4 CT abdomen : Finding consistent with subcapsular splenic

hematoma and hemorrhagic ascites. Transfusion 3 RBCs After blood transfusion SBP 120s. HR low 100s. Postransfusion H/H remained stable ~10/30

DOA # 5-6 H/H remained stable Mild tachycardia Serology for EBV - negative Hematology consult : No evidence of acute or chronic hematologycal

pathology Unknown cause for splenic rupture Recommends splenectomy for diagnostic purposes

DOA# 7 Laparoscopic splenectomy Blood clots in abdominal cavity, especially LUQ Subcapsular splenic hematoma Ruptured spleen Uneventful splenectomy was performed , hand

port placed for speciment removal

Postop Course POD # 2 Worsening of tachycardia to 130-140 SOB, Sat O2 low 90s, RR 20-25 BP 120-130/70-80 Stable H/H CXR – Lt pleural effusion CTA chest – no evidence of PE, worsening of lt

pleural effusion, total athelectasis LLL

Postop Course POD # 2-7 Aggressive pulmonary toilet Chest PT Improvement of respiratory status and tachycardia,

sat O2 WBC raising to max 26k then decreased and

stabilized in range 18-19k PLT progressively increased to > 1mln, ASA

initiated

POD# 9 Patient was d/c home On d/c day patient was given vaccinations: Pnemovax Hemophilus infuenzae B vaccine Neisseria meningitis vaccine

Pathology Congested spleen showing acute splenitis

and subcapsular and pericapsular hematoma associated with spontaneous rupture of spleen. Occasional abnormal and thickened hilar and intrasplenic blood vessels focally extending into the area of capsular hematoma .

Comment: In the absence of a clinical history of trauma, the splenic rupture is most likely spontaneous and due to acute splenitis. The possibility of a splenic vascular malformation cannot be entirely ruled out.

Acute splenitis Reflect septic state, neutrophilic infiltrate and

congestion within the red pulp accompanied by splenomegaly

Acute non-specific splenitis as indicator of systemic infection. Assessment of 71 autopsy cases (2) : Group A , 34 cases, cause of death sepsis Group B , 37 cases, cause f death non-

infectiousGroup A – splenitis observed in 79%Group B – no splenitis found

Earlyest reportCase of Acute Splenitis . Provincial Medical and Surgical Journal 1843 July 29; 6(148): 357–358.

20 yo F with catarrho-reumatic symptoms Initial treatment:

Case of Acute Splenitis . Provincial Medical and Surgical Journal 1843 July 29

Readmission in 2 days with worsening of symptoms and physical finding:

Case of Acute Splenitis . Provincial Medical and Surgical Journal , 1843 July 29

Treatment:

Outcome – patient recovered

Systematic review of atraumatic splenic rupture.British Journal of Surgery 2009; 96: 1114–1121

Terminology : Spontaneous rupture Pathological Atraumatic Occult Idiopatic Pathological fracture

Atraumatic splenic rupture (1)

632 publications reporting 845 patients 30 new patients per year over 28 years 2:1 male predominance Age 18-86, mean age 45 All patients denied any trauma

Etiology

711 (84.1%) – single etiological factor 59 ( 7%) – no etiological factor was found 69 (8.2%) – two underlying pathology 6 ( 0.7%) – combination of 3 factors

There are 6 major etiological groups

Etiology1. Neoplastic2. Infectious3. Inflamatory non-infectious4. Drug related5. Mechanical6. Normal spleen

Etiology The three commonest causes of ASR:

Malignant hematological disorders 16.4%

Viral infectious disorders 14.8%

Local inflamatory /neoplastic disorders 10.9%

Diagnostic procedures (1)

Final Dx of Splenic rupture : Laparotomy 42.3% CT scan 32.4% US 18.6% Scintigraphy 0.7% Laparoscopy 0.5% Angiogram 0.3% Post-mortem 5.2%

Treatment of splenic rupture in 774 patients(1)

17% of delayed rupture and rebleeding in conservative group which required splenectomy

Multivariable logistic regression analysis of risk factorsfor atraumatic splenic rupture-related mortality in 845 patients

Multivariable logistic regression analysis of risk factorsfor atraumatic splenic rupture-related mortality in relation to926 aetiological factors

Overwhelming postsplenectomy sepsis(OPSS)

Reduced post-splenectomy levels of opsonins, splenic tuftsin, and immunoglobulin (IgM)

Decrease the body’s ability to clear encapsulated organisms: Streptococcus pneumoniae Haemophilus influenzae type b Neisseria meningitidis.

Incidence of OPSS is estimated to be 0.05% to 2%

It may develop immediately or as late as 65 years postsplenectomy

Mortality is significant and reported to be as high as 50%

As 50 to 90% of OPSS infections are secondary to Streptococcus pneumoniae infection

Vaccination, to impart immunity against encapsulated organisms, is commonly performed

No Class I or Class II data to support efficacy vaccination

Pneumococcal vaccine results in the highest antibody titers when administered 14 days postsplenectomy ( class 1 studies16-17)

Current Center forDisease Control (CDC) recommendations for post-splenectomy vaccinations

Summary 93% of ASR associated with underlying spleen

pathology – “atraumatic pathological rupture” 7% there is no underlying pathology – “idiopatic

atraumatic splenic rupture” ASR of unknown etiology should undergo total

splenectomy for diagnostic purpose

Reference

1. Systematic review of atraumatic splenic rupture.British Journal of Surgery 2009; 96: 1114–1121

2. Acute non-specific splenitis as indicator of systemic infection. Assessment of 71 autopsy cases. Invest Clin. 2004 Jun;45(2):131-5.

3. Shatz DV et.al. Antibody responses in postsplenectomy trauma patients receiving the 23-valent pneumococcal polysaccharide vaccine at 14 versus 28 days postoperatively. J Trauma 2002; 53:1037-1042.

4. Shatz DVet.al. Antibody responses in postsplenectomy trauma patients receiving the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy. J Trauma 1998; 44(6):760-766.

5. Case of Acute Splenitis . Provincial Medical and Surgical Journal1843 July 29; 6(148): 357–358.

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