Andrius Račiūnas1
1Royal London Hospital, Barts Health NHS Trust, Ear, Nose & Throat Department, London, United Kingdom
Abstract:
Introduction. Atraumatic splenic rupture (ASR), also known as spontaneous splenic rupture, is a rare, potentially life-threatening condition that can be a result of infection, malignancy, inflammation, and a complication of various surgical procedures. There are not enough studies about patient characteristics, incidence rates, aetiology, and guidelines for management associated with ASR.
Clinical case. A 53-year-old gentleman had a transoral robotic resection of the left tongue base/aryepiglottic fold carcinoma and level 2-4 neck dissection. Subsequently, he had a radiologically inserted gastrostomy (RIG) for his dysphagia and airway protection. Two days after RIG was inserted, the patient collapsed in the ward. Blood tests were done and showed a severe haemoglobin level drop from 123 g/L to 73 g/L. Computer Tomography (CT) of the abdomen showed splenic bleeding. He had emergency laparotomy with splenectomy which showed no signs of traumatic spleen rupture secondary to RIG insertion. A histopathology sample taken in theatre showed no pathological changes in the spleen. There were no other causes apart from apixaban which was stopped before the procedure and resumed 24 hours after RIG insertion.
Conclusion. ASR is a rare event in healthcare and the symptoms are not specific. Abdominal pain on the left side that can spread to the shoulder, a decrease in haemoglobin level, and signs of haemorrhagic shock are all possible signs of bleeding in the spleen. Anticoagulant therapies such as apixaban, rivaroxaban, direct-acting oral anticoagulants (DOAC), and dabigatran are linked to instances of ASR.
Keywords. Atraumatic splenic rupture, splenectomy, radiologically inserted gastrostomy, apixaban.
Journal of Medical Sciences. July 25, 2022 - Volume 10 | Issue 3. Electronic - ISSN: 2345-0592
109
Medical Sciences 2022 Vol. 10 (3), p. 109-114,
https://doi.org/10.53453/ms.2022.07.13
Atraumatic splenic rupture in a patient after apixaban use and
radiologically inserted gastrostomy – a case report
Andrius Račiūnas
1
1
Royal London Hospital, Barts Health NHS Trust, Ear, Nose & Throat Department, London, United Kingdom
Abstract:
Introduction. Atraumatic splenic rupture (ASR), also known as spontaneous splenic rupture, is a rare, potentially
life-threatening condition that can be a result of infection, malignancy, inflammation, and a complication of
various surgical procedures. There are not enough studies about patient characteristics, incidence rates, aetiology,
and guidelines for management associated with ASR.
Clinical case. A 53-year-old gentleman had a transoral robotic resection of the left tongue base/aryepiglottic fold
carcinoma and level 2-4 neck dissection. Subsequently, he had a radiologically inserted gastrostomy (RIG) for his
dysphagia and airway protection. Two days after RIG was inserted, the patient collapsed in the ward. Blood tests
were done and showed a severe haemoglobin level drop from 123 g/L to 73 g/L. Computer Tomography (CT) of
the abdomen showed splenic bleeding. He had emergency laparotomy with splenectomy which showed no signs
of traumatic spleen rupture secondary to RIG insertion. A histopathology sample taken in theatre showed no
pathological changes in the spleen. There were no other causes apart from apixaban which was stopped before the
procedure and resumed 24 hours after RIG insertion.
Conclusion. ASR is a rare event in healthcare and the symptoms are not specific. Abdominal pain on the left side
that can spread to the shoulder, a decrease in haemoglobin level, and signs of haemorrhagic shock are all possible
signs of bleeding in the spleen. Anticoagulant therapies such as apixaban, rivaroxaban, direct-acting oral
anticoagulants (DOAC), and dabigatran are linked to instances of ASR.
Keywords. Atraumatic splenic rupture, splenectomy, radiologically inserted gastrostomy, apixaban.
Introduction
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Splenic rupture is typically caused by trauma. In some
rare cases, it can be atraumatic. ASR, also known as
spontaneous splenic rupture, is a rare, potentially life-
threatening condition that can be a result of infection,
malignancy, inflammation, and a complication of
various surgical procedures (1,2). It is also reportedly
associated with apixaban use in some published
clinical cases (3,4,5,6).
There are not enough studies about patient
characteristics, incidence rates, aetiology, and
guidelines for management associated with ASR
(1,2,7).
ASR is confirmed by CT scan or laparotomy if the
patient is haemodinamically unstable. There are
several grading systems established for splenic rupture
based on CT scan and/or ultrasound findings which
helps with management and decision making (8).
Case presentation
A 53-year-old gentleman was admitted under Ear,
Nose & Throat (ENT) for transoral robotic resection of
the left tongue base/aryepiglottic fold carcinoma and
level 2-4 neck dissection. He has a past medical history
of squamous cell carcinoma of the epiglottis and
previous pulmonary embolism for which he is taking
apixaban.
Following the procedure, the patient was seen by ENT
and Speech and Language Therapists. Both teams did
a videofluoroscopy and fiberoptic endoscopic
evaluation of swallowing tests which showed moderate
to severe pharyngeal dysphagia secondary to the
procedure he had. His dysphagia was characterized by
reduced airway protection (due to lack of epiglottis and
vallecular space) resulting in persistent airway
penetration and consistent post-swallow pooling of
residue. Reversibility was unclear, therefore both
teams agreed that the patient requires radiologically
inserted gastrostomy (RIG) until his swallowing
function improves. Subsequently, he had a nasogastric
tube inserted.
Two weeks later, the interventional radiology (IR)
team inserted RIG. There were no complications after
the procedure apart from mild pain in his abdomen
which is expected after the procedure. The following
day his haemoglobin (Hb) levels were stable (123 g/L).
The pain in the abdomen was still mild and persistent.
Two days after RIG was inserted, the patient collapsed
in the ward. Nurses immediately called Critical Care
Outreach and ENT teams who examined the patient. He
was stable but looked very paled. After examination,
both teams assumed he had a vasovagal episode;
however, blood tests were done and showed a severe
Hb drop from 123 g/L to 73 g/L which indicated that
the patient is having active bleeding. In light of the mild
abdominal pain/distention and recent surgery, the ENT
team requested CT of the abdomen scan on the same
night which showed a large intra-abdominal
haematoma with active bleeding and a large volume
haemoperitoneum (Fig. 1, Fig. 2). The splenic rupture
was likely a cause as the radiologist was not able to
identify and separate the haematoma. IR team also
reviewed images. They had an impression that the
patient has venous bleeding which is unlikely related to
the RIG procedure.
A general surgeon reviewed the patient and decided to
take him to the theatre. Whilst he was waiting for his
surgery, he received 4 units of red blood cells, 2 units
of fresh frozen plasma, 1g of tranexamic acid and 3000
units of octaplex which stabilized his Hb levels to 88.
He had emergency laparotomy with splenectomy
which showed no signs or indications of traumatic
spleen rupture secondary to RIG insertion. It was
suspected that the patient had spontaneous spleen
rupture which is not associated with RIG and likely was
caused by apixaban use. The patient felt much better
after the surgery with no metabolic disturbance or
requirement for advanced organ support. He received
pneumococcal, meningococcal, and haemophilus
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111
vaccinations and was discharged from the hospital with
life-long penicillin prophylaxis seven days later.
Figure 1. Coronal view of splenic rupture. A hypodense area marked with an arrow shows fluid between
ruptured spleen. There is also visible fluid in peritoneum.
Figure 2. Axial view of splenic rupture. Spleen cannot be verified and separated from haematoma. A hypodense
area marked with an arrow shows fluid between ruptured spleen.
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Discussion
ASR is a rare event in healthcare. Medical procedures
such as colonoscopy, hysterectomy, endoscopic
retrograde, and cholangiopancreatography are reported
to be a frequent cause of splenic injury (9). There have
been no reports in the literature of actual spleen injury
when a RIG tube was inserted (10). After discussion
with the general surgeon who did laparotomy, we
found out that there was no obvious connection
between the RIG tube and spleen. Although the patient
had a fall which can also contribute to splenic rupture,
he was already feeling unwell before it. Thus, a fall was
likely related to orthostatic syncope secondary to low
intravascular volume from preceding splenic
haemorrhage. A histopathology sample from spleen
showed retained architecture and no overt pathological
changes except for evidence of rupture. There were no
other causes apart from apixaban which was stopped
before the procedure and resumed 24 hours after RIG
insertion.
As mentioned before, anticoagulant therapies such as
apixaban, rivaroxaban, DOAC, and dabigatran are
linked to instances of ASR (3). Anti-fibrinolytic
therapy along with tissue plasminogen activator and
streptokinase has also been associated with ASR (11).
The symptoms of ASR are not specific. Abdominal
pain on the left side that can spread to the shoulder, a
decrease in haemoglobin level, signs of haemorrhagic
shock are all possible signs of bleeding in the spleen
(12). Due to the non-specific clinical picture, it can be
easily confused with peptic ulcer or heart disease in the
absence of trauma. Our patient only had mild
abdominal pain after the procedure which didn’t
indicate any obvious signs of intraabdominal bleeding
until he collapsed on the floor. After further
investigations, we found out he had low haemoglobin
levels and signs of haemorrhagic shock.
Over the years, the management of splenic injuries has
changed from surgical to non-surgical (13). Improved
diagnostic and monitoring tools and advances in
interventional radiology have contributed to this
management (14). Splenic angioembolization should
be considered in haemodynamically stable patients.
Our patient was haemodynamically unstable; therefore,
he had laparotomy and splenectomy.
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