Spontaneous Splenic Rupture in a Non-Traumatic Patient: A Case Study

Abstract

Spontaneous splenic rupture (SSR) is a rare but life-threatening clinical condition characterized by splenic hemorrhage in the absence of trauma. It may occur in association with infections, hematologic disorders, inflammatory conditions, or anticoagulant use, and can also arise in a previously normal spleen. Clinical presentation is often non-specific, leading to delayed diagnosis and increased mortality. We report a case of a middle-aged male presenting with acute abdominal pain and hemodynamic instability without any history of trauma. Imaging confirmed splenic rupture with hemoperitoneum, and the patient was successfully managed with emergency splenectomy. This case emphasizes the importance of early recognition and prompt intervention in non-traumatic acute abdomen.

Introduction

The spleen is most commonly injured following blunt abdominal trauma; however, spontaneous splenic rupture refers to rupture occurring without any antecedent traumatic event [1]. Although uncommon, it is a recognized surgical emergency and has been reported in association with infections, hematologic malignancies, inflammatory disorders, coagulation abnormalities, and anticoagulant therapy [2,3].

Clinical manifestations range from mild abdominal discomfort to sudden onset of severe abdominal pain accompanied by hypovolemic shock [4]. The absence of a trauma history often delays diagnosis, increasing morbidity and mortality [5]. Contrast-enhanced computed tomography (CT) is the imaging modality of choice for confirming the diagnosis and guiding management [1,4].

Patient Information

Age / Gender: 48-year-old male
Medical History: Hypertension
Medication History: Antihypertensive medications; no anticoagulant or antiplatelet use
Surgical History: None
Social History: Non-smoker, occasional alcohol use
Chief Complaint: Sudden onset left upper abdominal pain with dizziness

Clinical Findings

The patient presented to the emergency department with acute, severe left upper quadrant abdominal pain radiating to the left shoulder (Kehr’s sign), associated with nausea, dizziness, and a brief syncopal episode. There was no history of trauma, strenuous activity, coughing spells, or recent medical procedures.

On examination, the patient appeared pale and diaphoretic. Vital signs revealed hypotension and tachycardia, indicating hemodynamic instability. Abdominal examination showed tenderness, guarding, and mild distension in the left upper quadrant with reduced bowel sounds. No external signs of injury were present. These findings raised strong suspicion for an acute intra-abdominal hemorrhagic event [4,5].

Timeline

• Day 0: Sudden onset abdominal pain and syncope
• Emergency Admission: Hemodynamic instability identified
• Same Day: Contrast-enhanced CT abdomen performed
• Same Day: Emergency splenectomy
• Postoperative Period: Hemodynamic stabilization
• Discharge: Day 7

Diagnostic Assessment

Laboratory investigations demonstrated acute anemia with a significant drop in hemoglobin levels and mild leukocytosis. Coagulation parameters, liver function tests, and renal function tests were within normal limits.

Contrast-enhanced CT of the abdomen revealed splenic enlargement with capsular disruption, intraparenchymal hematoma, and a large volume of hemoperitoneum. Active contrast extravasation was noted, confirming ongoing hemorrhage. No traumatic injuries or focal splenic lesions were identified, consistent with spontaneous splenic rupture [1,3,4].

Diagnosis

Spontaneous splenic rupture with hemoperitoneum in a non-traumatic patient [2].

Therapeutic Intervention

Given the patient’s hemodynamic instability and evidence of active bleeding on imaging, emergency exploratory laparotomy was performed. Intraoperatively, a ruptured spleen with extensive hemorrhage was identified without involvement of adjacent organs. Total splenectomy was performed to achieve definitive hemorrhage control.

Postoperatively, the patient received blood transfusions, intravenous fluids, and prophylactic antibiotics. Vaccinations against encapsulated organisms were administered in accordance with post-splenectomy guidelines [3,5].

Follow-Up and Outcomes

The postoperative course was uneventful, with the patient demonstrating steady clinical improvement. Hemodynamic parameters stabilized promptly following surgery, and serial monitoring showed gradual normalization of hemoglobin levels without the need for additional transfusions. The patient tolerated resumption of oral intake well, with no gastrointestinal complications, and was mobilized early during the recovery period. There were no signs of postoperative infection, bleeding, or other surgical complications, and overall recovery was smooth.

Histopathological examination of the excised spleen revealed features of congestion and subcapsular hemorrhage, without evidence of malignancy, infiltrative disease, or underlying splenic pathology. These findings supported the diagnosis of spontaneous rupture of a previously normal spleen, reinforcing the non-traumatic nature of the event. At follow-up, the patient remained asymptomatic and in good general health. He was counseled extensively regarding the lifelong increased risk of overwhelming post-splenectomy infection and the importance of prompt medical evaluation for any febrile illness, as well as adherence to recommended vaccination schedules and preventive measures [5].

Discussion

Spontaneous splenic rupture is a rare but potentially fatal clinical entity that requires a high index of suspicion for timely diagnosis, particularly in patients presenting with acute abdominal pain and hemodynamic instability [1]. Although the majority of reported cases occur in the setting of underlying splenic pathology such as infectious diseases, hematologic malignancies, inflammatory disorders, or coagulation abnormalities, rupture of an apparently normal spleen has also been well documented in the literature [2,3]. The pathophysiological mechanisms proposed to explain spontaneous rupture include sudden increases in intrasplenic pressure, vascular congestion leading to capsular tension, and underlying microstructural weakness of the splenic parenchyma, even in the absence of overt disease [4].

The absence of a preceding history of trauma frequently contributes to delayed or incorrect diagnosis, as clinical presentation may closely mimic other causes of acute abdomen such as acute pancreatitis, perforated peptic ulcer, ruptured abdominal aortic aneurysm, or hollow viscus perforation [5]. Symptoms may be nonspecific in the early stages, further complicating clinical assessment. However, the presence of left upper quadrant abdominal pain radiating to the left shoulder (Kehr’s sign), unexplained hypotension, or a sudden drop in hemoglobin levels should prompt urgent radiological evaluation [4,5]. Contrast-enhanced computed tomography remains the gold standard for diagnosis, allowing accurate assessment of splenic injury, active hemorrhage, and associated hemoperitoneum, as well as aiding in therapeutic decision-making [1].

Management strategies for spontaneous splenic rupture are primarily guided by the patient’s hemodynamic status and the extent of splenic injury [1,4]. Hemodynamically unstable patients require immediate surgical intervention, most commonly splenectomy, to achieve definitive hemorrhage control and prevent fatal outcomes. In contrast, carefully selected hemodynamically stable patients without ongoing bleeding may be considered for conservative management or splenic artery embolization, provided that close monitoring and immediate surgical backup are available [1,4]. Early recognition and appropriate management remain crucial determinants of survival in this rare but life-threatening condition.

Conclusion

Spontaneous splenic rupture should be carefully considered in patients who present with sudden-onset acute abdominal pain accompanied by signs of hemodynamic instability, even when there is no history of recent trauma or injury. The absence of an obvious precipitating event often leads to diagnostic delay; therefore, maintaining a high index of clinical suspicion is essential, particularly in patients with unexplained hypotension, anemia, or left upper quadrant abdominal tenderness.

Early use of appropriate imaging modalities, especially contrast-enhanced computed tomography, allows for rapid identification of splenic injury, active hemorrhage, and associated hemoperitoneum. Prompt diagnosis followed by timely surgical intervention, most commonly splenectomy in unstable patients, is critical to prevent catastrophic hemorrhage and fatal outcomes. Increased awareness among emergency physicians, surgeons, and internists regarding this rare but life-threatening condition can significantly facilitate early recognition, reduce diagnostic delays, and ultimately improve patient survival and clinical outcomes.

References

1. Renzulli P, Hostettler A, Schoepfer AM, et al. Systematic review of atraumatic splenic rupture. Br J Surg. 2009;96(10):1114–1121.
2. Orloff MJ, Peskin GW. Spontaneous rupture of the normal spleen. Int Abstr Surg. 1958;106(1):1–11.
3. Kocael PC, Simsek O, Bilgin IA, et al. Characteristics of patients with spontaneous splenic rupture. Int Surg. 2014;99(6):714–718.
4. Ashrafian H, Davey P. Spontaneous splenic rupture. J R Soc Med. 2001;94(10):504–505.
5. Imbert P, Rapp C. Spontaneous splenic rupture in infectious diseases. Rev Med Interne. 2004;25(8):565–571.

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