Splenic rupture in the absence of trauma is exceedingly rare. Although atraumatic splenic rupture (ASR) is uncommon, it warrants early recognition due to the potentially fatal consequences and thus should be included in the differential diagnosis of patients with left upper quadrant abdominal pain . A recent systematic review of atraumatic splenic rupture found there to be six major etiological groups: neoplastic processes (30.3%), infectious (27.3%), inflammatory (20.0%), iatrogenic (9.2%), mechanical (6.8%), and normal spleen (6.4%) . ASR of the normal spleen is defined by four criteria: no history of trauma, no evidence of extrasplenic disease known to affect the spleen, no perisplenic adhesions to suggest previous trauma, and normal spleen on gross and histologic exam .
Clinical presentation of ASR mimics traumatic splenic rupture. Abdominal pain, especially in the left upper quadrant, or chest pain with radiation to the left shoulder, caused by subdiaphragmatic irritation, are classic symptoms of splenic pathology. There is often little or no clinical history to suggest splenic pathology, and the diagnosis is often made after imaging, which often includes ultrasonography or CT scan .
There are no definitive guidelines on management of ASR, although it is often modeled after that of traumatic splenic rupture. Treatment may include operative or non-operative therapy, depending upon the patient’s hemodynamic stability and degree of splenic injury. The large amount of fluid within the abdomen could support operative evaluation with exploratory laparotomy. Factors favoring non-operative management in this case included total clinical stability, a soft abdomen, and duration of greater than 24 hours from the inciting event. The American Association for the Surgery of Trauma criteria for degree of splenic injury correlates with failure of conservative treatment. Given that a splenic etiology was not confirmed until the ultrasound after discharge, his injury could not be graded. At the time of follow-up, the subcapsular hematoma measured less than 10% of the surface area, consistent with a grade 1 injury . Even in the setting of non-operative management, surgical teams are often involved or are the primary team managing inpatient surveillance. Work-up in patients with ASR should include studies to rule out the common causes, including neoplastic, infectious, and inflammatory processes. As this patient’s work-up was negative, we conclude that the patient had a normal spleen with ASR and associate the splenic rupture with cocaine use.
Cocaine use remains epidemic and is associated with a wide range of medical complications. The well-studied physiologic effects of cocaine include increased norepinephrine reuptake with sustained alpha-adrenergic receptor stimulation and resultant vasoconstriction. Cocaine-associated vasoconstriction was shown to transiently reduce splenic volume on average by 20% . This vasoconstriction transiently elevates blood pressure. In addition, increased abdominal venous pressure due to cough could suggest an inciting event for splenic hemorrhage in this patient. This has been previously described in a case report of a patient with hemoperitoneum after ingestion of cocaine and associated acute emesis; however, no etiologic source or evidence of underlying pathology was found .
Splenic infarction following cocaine use is rare but has been described, particularly in patients with sickle hemoglobinopathies . It is plausible that cocaine-associated splenic hematoma or rupture results from transient vasospasm with subsequent bleeding into the infarcted area. Secondary infection of the infarcted spleen with resultant sepsis and death has also been detailed .
While the use of cocaine causing hematoma of the spleen has been described , this case is the first report of a case that details hemoperitoneum caused by ASR following cocaine use. Although uncommon, the potential for death due to splenic rupture warrants awareness and highlights the importance of a social history in patients presenting with acute abdominal pain.
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