Trivial Trauma and Delayed Rupture of a Normal Spleen
Trivial Trauma and Delayed Rupture of a Normal Spleen
Introduction: Although a majority of splenic ruptures present acutely with a known mechanism of injury, a minority of patients present days to weeks following trauma with a delayed rupture. Also uncommon is the atraumatic rupture, the vast majority of which occur in patients with underlying splenic pathology. A handful of cases of apparently spontaneous rupture of a normal spleen are reported; however, there is debate about whether these actually represent delayed ruptures following a history of trauma that is not elicited. Although a few cases of delayed rupture of the spleen following trivial trauma have been reported, the majority of these present evidence of an underlying disease process. We found only two such cases that documented a normal spleen and three cases where underlying splenic pathology was not reported. We review the literature and discuss the phenomenon of delayed rupture of the normal spleen following trivial trauma.
Case presentation: A 27-year-old Caucasian man with no underlying splenic pathology presented with splenic rupture one week after playfully wrestling with his partner. The patient did not present at the time of the injury and only recalled it upon repeated questioning after computed tomography diagnosis.
Conclusions: This case lends support to the theory that the normal spleen can rupture some time after trivial trauma, which seems like a more plausible explanation than rupture without cause. However, given the dearth of similar reports in the literature, the possibility remains that the association we have observed is not causational.
In patients sustaining blunt abdominal trauma, the spleen is the most commonly damaged viscus. Although a majority of patients with this injury present acutely, up to 15% present with a delayed rupture days to weeks following a substantial abdominal injury. The mortality for patients presenting with acute splenic rupture is approximately 1% whereas the mortality associated with delayed rupture approaches 15%. While atraumatic rupture of the spleen is not unheard of, cases reported in the literature of such a rupture are rare and usually occur in a diseased spleen.
There is debate in the literature as to whether apparently atraumatic ruptures of the spleen are truly spontaneous or actually represent a delayed rupture following a history of trauma that is not elicited at the time of presentation (reviewed in ). In 1958, Orloff and Peskin proposed four criteria to define what they refer to as 'spontaneous' rupture of a spleen, which emphasizes that the spleen must appear grossly and histologically normal. In the same paper, they cite 71 reports documenting ruptures of the spleen labelled as spontaneous, only 20 of which fulfilled all of their criteria. Thus, usage of the term spontaneous was inconsistent and continues to be so in the more recent literature, with many authors labeling the rupture of diseased spleens as spontaneous.
We present the case of a 27-year-old Caucasian man without risk factors for rupture and an apparently normal spleen who presented with a delayed rupture and significant hemoperitoneum one week after sustaining a left sided abdominal injury. The injury was so minor that the patient did not present for assessment at the time and only recalled the incident following radiological diagnosis and subsequent questioning. We found only two cases of delayed rupture of normal spleen following trivial trauma reported in the literature in the last 60 years. In one case, the spleen was enlarged and in the other, splenic size and weight were not reported. Three other reports of delayed rupture following such trauma published in the same time period did not include information on evidence of splenic disease. Given that the spleen was enlarged in the first case, not reported in the second case and that disease information was not reported in the other three, the possibility remains that all of these represent ruptures of diseased spleens, and that our case is the first report of delayed rupture of a normal spleen following trivial trauma. Given the dearth of publication in this area, the possibility remains that the associations observed in these reports are coincidental rather than causal. However, we feel that documenting these cases may lead to improved recognition of similar cases in the future and possibly to an enhanced understanding of the pathophysiology of splenic rupture.
Abstract and Introduction
Abstract
Introduction: Although a majority of splenic ruptures present acutely with a known mechanism of injury, a minority of patients present days to weeks following trauma with a delayed rupture. Also uncommon is the atraumatic rupture, the vast majority of which occur in patients with underlying splenic pathology. A handful of cases of apparently spontaneous rupture of a normal spleen are reported; however, there is debate about whether these actually represent delayed ruptures following a history of trauma that is not elicited. Although a few cases of delayed rupture of the spleen following trivial trauma have been reported, the majority of these present evidence of an underlying disease process. We found only two such cases that documented a normal spleen and three cases where underlying splenic pathology was not reported. We review the literature and discuss the phenomenon of delayed rupture of the normal spleen following trivial trauma.
Case presentation: A 27-year-old Caucasian man with no underlying splenic pathology presented with splenic rupture one week after playfully wrestling with his partner. The patient did not present at the time of the injury and only recalled it upon repeated questioning after computed tomography diagnosis.
Conclusions: This case lends support to the theory that the normal spleen can rupture some time after trivial trauma, which seems like a more plausible explanation than rupture without cause. However, given the dearth of similar reports in the literature, the possibility remains that the association we have observed is not causational.
Introduction
In patients sustaining blunt abdominal trauma, the spleen is the most commonly damaged viscus. Although a majority of patients with this injury present acutely, up to 15% present with a delayed rupture days to weeks following a substantial abdominal injury. The mortality for patients presenting with acute splenic rupture is approximately 1% whereas the mortality associated with delayed rupture approaches 15%. While atraumatic rupture of the spleen is not unheard of, cases reported in the literature of such a rupture are rare and usually occur in a diseased spleen.
There is debate in the literature as to whether apparently atraumatic ruptures of the spleen are truly spontaneous or actually represent a delayed rupture following a history of trauma that is not elicited at the time of presentation (reviewed in ). In 1958, Orloff and Peskin proposed four criteria to define what they refer to as 'spontaneous' rupture of a spleen, which emphasizes that the spleen must appear grossly and histologically normal. In the same paper, they cite 71 reports documenting ruptures of the spleen labelled as spontaneous, only 20 of which fulfilled all of their criteria. Thus, usage of the term spontaneous was inconsistent and continues to be so in the more recent literature, with many authors labeling the rupture of diseased spleens as spontaneous.
We present the case of a 27-year-old Caucasian man without risk factors for rupture and an apparently normal spleen who presented with a delayed rupture and significant hemoperitoneum one week after sustaining a left sided abdominal injury. The injury was so minor that the patient did not present for assessment at the time and only recalled the incident following radiological diagnosis and subsequent questioning. We found only two cases of delayed rupture of normal spleen following trivial trauma reported in the literature in the last 60 years. In one case, the spleen was enlarged and in the other, splenic size and weight were not reported. Three other reports of delayed rupture following such trauma published in the same time period did not include information on evidence of splenic disease. Given that the spleen was enlarged in the first case, not reported in the second case and that disease information was not reported in the other three, the possibility remains that all of these represent ruptures of diseased spleens, and that our case is the first report of delayed rupture of a normal spleen following trivial trauma. Given the dearth of publication in this area, the possibility remains that the associations observed in these reports are coincidental rather than causal. However, we feel that documenting these cases may lead to improved recognition of similar cases in the future and possibly to an enhanced understanding of the pathophysiology of splenic rupture.