Asymptomatic spontaneous splenic rupture – a hair-raising experience in the operating room

摘要

BackgroundSpontaneous splenic rupture (SSR) is a rare surgical complication of hematological malignancies like hairy-cell leukemia and asymptomatic SSR is even rarer. SSR is defined as rupture of spleen in absence of any preceding trauma.Material and methodsWe present a case report of a 35-year-old male patient who was a diagnosed with hairy-cell leukemia with massive splenomegaly. The patient was referred to us by the hemato-oncologist for splenectomy since the patient had hypersplenism and complained of dragging sensations in the abdomen due to an enormous spleen measuring 18 centimeters below the left costal margin. The patient was hemodynamically stable except for low hemoglobin and was prepared for elective splenectomy. Laparotomy was preformed and there were around 3.5 liters of hemoperitoneum, with the splenic capsule densely adherent to the parietal peritoneum. Splenectomy was completed and the patient had an uneventful postoperative recovery. The diagnosis was confirmed by histopathological examination and marker study of the spleen.ResultsSplenic rupture presents as an abdominal emergency. The patient may become exsanguinated in a short interval of time. These are usually patients with splenomegaly presenting in the emergency department with complaints of sudden-onset pain in the left upper quadrant of the abdomen with symptoms of hypotension like dizziness. On examination, the patient is usually in hemodynamic compromise with tachycardia and hypotension. Abdominal examination may reveal signs of peritonitis. A falling hematocrit may be seen on serial hemograms. Radiological investigations (ultrasonography and CT scan of the abdomen) showing hemoperitoneum are helpful in clinching the diagnosis of splenic rupture in patients with splenomegaly presenting with abdominal pain and hypotension. The management entails an adequate resuscitation and an emergency splenectomy. More cases of asymptomatic splenic rupture have to be studied before outlining a definite management protocol, especially the indications of surgery in these patients.ConclusionThe aim of this case report is to draw attention of the oncologists and surgeons towards this rare asymptomatic complication of hematological malignancies like hairy-cell leukemia which may come as a surprise at the time of laparotomy and envisage a diagnostic work-up for patients with splenomegaly. Background SSR is a very rare complication[1] of hairy-cell leukemia. Symptomatic SSR is an abdominal catastrophe with patients presenting with hemodynamic instability[2]. This requires urgent diagnosis and emergency surgery. The majority of cases of splenic rupture are those of diseased spleen and are called ‘pathological rupture of spleen’. ‘True spontaneous rupture of spleen’, which is very rare, is the rupture of normal spleen. Infections are the most common cause of splenic rupture[345678]. Case report We present a case of a 35-year-old male patient who was referred to us by the hemato-oncologist as a diagnosed case of hairy-cell leukemia. The patient had developed features of hypersplenism and had a persistent dragging sensation in the abdomen. These were consequence of a massive splenomegaly.On general physical examination there was marked pallor and cervical lymphadenopathy. The heart and the lungs were normal. On per abdomen examination there was no tenderness, guarding or rigidity. The spleen was palpable 18cm below the left subcostal margin.In the preoperative work-up of the patient the hemoglobin was 5.4g%, total leukocyte count was 0.46x103/ml and the platelet count was 16x103/ml. A previously done CT scan of the abdomen and thorax revealed hepatosplenomegaly with generalized lymphadenopathy (figure 1).