Title: Sauder – Spontaneous Splenic Artery Rupture in Young Adult Male Without Risk Factors or Evidence for Aneurysm

Author(s): Michael Sauder, DO; Brian Gruber, MD

Email: Msauder@mercy.com

Introduction:  Spontaneous splenic artery rupture is a rare, but recognized clinical entity. Prior case reports have been published. However, the overwhelming majority of published instances have involved patients with at least one recognized risk factor for splenic artery aneurysm. Additionally, the majority of reported cases have involved individuals greater than 50 years of age. All currently published case reports of such occurrences have included radiologic evidence for splenic artery aneurysm. The following case describes a 27 year old male, who presented in extremis secondary to spontaneous splenic artery rupture. He had no risk factors for visceral artery aneurysm. No radiologic evidence for arterial aneurysm or contrast extravasation was present on abdominal CTA imaging.

Case Report(s):  A 27 year old male, with medical history significant only for remotely resected ependymoma, presented to the emergency department with complaints of fever, headache, epigastric discomfort, shortness of breath, and lethargy. The patient was not taking home medications and had no history of illicit substance use. On presentation, he was found to have serum lactate of 11.8. Shortly following presentation, he became hemodynamically unstable, deteriorating to the point of cardiac arrest twice. The patient underwent abdominal CTA imaging, showing intra-abdominal fluid concerning for blood. No aneurysmal disease or contrast extravasation was seen on imaging. The patient underwent exploratory laparotomy. Intra-operatively, he developed profound coagulopathy, hypothermia, and acidosis, with lowest recorded arterial pH of 6.665. A bleeding splenic artery defect was isolated. A damage control procedure consisting of distal pancreatectomy with splenectomy and temporary abdominal closure was performed. Following aggressive resuscitation, the patient’s abdomen was closed during third look laparotomy. The remainder of the patient’s post-operative course included the need for hemodialysis, pleural effusion requiring thoracentesis, pancreatic duct leak requiring ERCP with stenting, and intra-abdominal abscess requiring percutaneous drainage and intravenous antibiotics. The patient was ultimately discharged home.

Discussion:  This case highlights the rare, but life-threatening diagnosis of splenic artery rupture. Our case is unique due to the lack of patient risk factors and the absence of radiologic evidence on abdominal CTA for aneurysmal disease or contrast extravasation. Due to the severity of this condition, timely diagnosis and treatment is imperative. Splenic artery rupture is therefore an important differential diagnosis for all patients with concern for intra-abdominal bleeding, even when minimal risk factors or imaging findings are present.