Spontaneous spleen rupture due to rivaroxaban: a case report

Abstract

Introduction:

Splenic ruptures occurring without trauma are often called spontaneous or atraumatic splenic rupture. One of the uncommon causes of ASR are medicines, especially anticoagulants.

Case presentation:

We present an adult female with acute constant epigastric pain without any history of trauma taking prophylactic rivaroxaban. Patient had severe anemia and prolonged prothrombin and partial thromboplastin time and computed tomographic scan with intravenous contrast showed evidences of splenic rupture. We performed emergent splenectomy and discharged her after 6 days and tolerating oral diet.

Discussion:

Atraumatic (or spontaneous) splenic rupture is a rare and life-threatening condition. Several reports have described the association of ASR with anticoagulation therapies. Abdominal CT scan with IV contrast remains as the gold standard of diagnosis and discontinuation of oral anticoagulant and emergent surgery is the main treatment for unstable patients.

Conclusion:

Management of patients with ASR whilst taking a DOAC remains challenging and high degree of suspicion for splenic rupture in patients without trauma must be maintained.

Introduction

Splenic rupture often occurs in association with the trauma^[1^]. Ruptures occurring without trauma are often called spontaneous or atraumatic splenic rupture (ASR)^[2,3^]. ASRs are rare and the frequency is unclear^[4^]. Delayed diagnosis and management leading to approximately 12.2% mortality rate^[5^]. Main etiologies for ASR are infections, neoplasms and inflammation and rarer causes are medicines, specially anticoagulants^[2,6^].

In this report, we introduce an adult patient with acute abdominal pain without any history of trauma who diagnosed with ASR caused by administrated oral rivaroxaban. This work has been reported based on SCARE 2025 guidelines^[7^].

Case presentation

A 57-year-old female presented to our emergency department with acute, constant abdominal pain for the last 2 hours. The pain was more localized in the epigastric area. The patient did not report any history of melena, hematemesis, or trauma. However, we noted a history of spinal fusion surgery approximately 2 years ago, with subsequent postoperative pulmonary thromboembolism (PTE) and deep venous thrombosis (DVT), for which she had been taking 20 mg of Rivaroxaban daily.

HIGHLIGHTS

• Spontaneous spleen rupture is rare and life threatening, comprising about 5–10% of splenic ruptures with mortality around 20%.

• Distinguish pathological rupture from idiopathic/spontaneous rupture, which requires strict criteria.

• Presentation includes abdominal pain and signs of internal bleeding, often misdiagnosed without trauma history.

• Anticoagulation, especially direct oral anticoagulants, is associated with this pathology in several reports.

• Use ultrasound for unstable patients; contrast-enhanced CT is the gold standard, with surgery for instability and conservative care for stable cases, plus post-splenectomy vaccination.

Routine monitoring in the emergency unit revealed a blood pressure of 85/60 mm Hg, tachycardia (118 bpm), and a respiratory rate of 18 breaths per minute. Laboratory tests indicated severe anemia and prolonged prothrombin and partial thromboplastin times. Emergency ultrasound revealed mild free fluid around the stomach and spleen. Considering the epigastric tenderness and the absence of generalized tenderness, the patient was deemed a candidate for a computed tomographic scan (CT scan) after resuscitation for further diagnostic evaluation. After 1.5 hours from admission, a CT scan with intravenous contrast was performed, revealing a massive hematoma and active extravasation of contrast around the spleen without any signs of previous infarct (Fig. 1A and B). The imaging study ruled out other differential diagnosis (e.g., perforated ulcer, pancreatitis, and aortic aneurysm).

Figure 1.

(A and B) Spiral abdominopelvic CT scan with IV contrast (axial and coronal).

After 1 hour from performing the radiologic study and receiving two litters of lactated ringer, patient was then transferred to the operating room for an emergency splenectomy. We performed a midline laparotomy below and above umbilicus and evidence of bleeding and blood clots was noted around the liver. After evacuation and packing, a thorough abdominal explore revealed bleeding around the splenic hilum. Due to the impossibility of splenorrhaphy, we performed a total splenectomy. A pezzer drainage was established in the site of splenectomy. Patient received three units of packed red blood cells and two units of fresh frozen plasma (FFP). After achieving proper hemostasis, her vital signs stabilized and the patient was transferred to the intensive care unit.

After 24 hours, the patient was transferred to the surgical ward, and after 6 days of tolerating an oral diet, the patient was discharged without any further complications. Petzer drainage was removed before discharge and the patient received vaccination against encapsulated organisms was performed. The amount of hemoglobin before discharge was 12 g/dl. Because of the history previous PTE, anti-coagulation was continued under the supervision of cardiologist.

Hypodense massive area (150 × 113 × 138 mm) surrounding the spleen and scalloping its parenchyma, suggestive of a massive tension splenic hematoma, was observed. A central hyperdense focus indicated active extravasation of radiologic contrast.

Discussion

Atraumatic (or spontaneous) splenic rupture is a rare and life-threatening condition. It is usually associated with malignancies, viral infections and local inflammatory pathologies^[2^]. The incidence of ASR is relatively rare and has been reported in various studies, with estimates suggesting it accounts for approximately 5–0% of all splenic rupture cases^[8^]. Some studies suggest a slight male predominance, although data is not entirely consistent and the condition is most commonly observed in middle-aged to older adults, typically between the ages of 40 and 70 years^[2^]. Past studies showed significant mortality of ASR and greater complications in men^[2^]. The mortality rate for ASR can reach approximately 20%, influenced by factors like underlying health conditions such as diabetes or hematological malignancies and the timing of surgical intervention^[9,10^].

Common symptoms include abdominal pain, hypotension, and signs of internal bleeding, which may be misdiagnosed due to the absence of trauma^[11^]. Patients may present with splenic infarction or abscess, often complicating the clinical picture^[10^].

Atraumatic splenic rupture can be classified into two major categories: pathological rupture (occurring in a diseased spleen) and idiopathic rupture (occurring in a healthy spleen), also called “spontaneous rupture”^[3^]. An idiopathic rupture must meet four criteria: no history of trauma history, no other diseased organs that can cause splenic rupture, no peri-splenic adhesions or pre-existing scars, macroscopically and histologically normal spleen, and no increase in serological antibody titer in the acute and convalescent phases^[12,13^].

Considering the differential diagnosis of acute epigastric pain is crucial. Myocardial infarction, acute and chronic pancreatitis, peptic ulcer disease, mesenteric ischemia, gastroesophageal reflux disease, gastritis, and gastroparesis are some of the most common differential diagnoses^[14^]. ASR is not among the common diagnosis of acute epigastric pain^[15^].

Several reports have described the association of ASR with anticoagulation therapies^[16–20^]. DOACs (direct-acting oral anticoagulants) are direct inhibitors for thrombin or activated factor X (FXa)^[21^]. Dabigatran, rivaroxaban, apixaban, and edoxaban are licensed in many regions for use in several indications related to anticoagulation, including the prophylaxis and treatment of VTE, prevention of stroke and systemic embolic events (SEE) in non-valvular atrial fibrillation (NVAF), and secondary prevention of major adverse cardiovascular events an acute coronary syndrome with elevated biomarkers^[22,23^].

Ultrasound may also be utilized for initial evaluation, particularly in unstable patients^[24^]. A triphasic dynamic contrast-enhanced CT scan is the preferred imaging modality for diagnosing ASR, allowing for assessment of vascular integrity and active bleeding and further grading for proper treatment^[24^]. Hemodynamic status has a critical role in diagnostic procedure of ASR. Intravenous contrast computed tomography of the abdomen remains the gold standard for stable or well-stabilized patients with sensitivity and specificity of at least 95%^[25,26^]. In most cases, treatment consists of discontinuation of oral anticoagulant and emergent surgery for unstable patients^[25^]. However, hemodynamically stable patients with are normally treated conservatively^[27^].

Preoperative care may include blood transfusions for stabilization and antibiotic prophylaxis to prevent infections post-splenectomy. Vaccinations against pneumococcus, meningococcus, and Haemophilus influenzae are recommended post-splenectomy to mitigate infection risks^[24^].

Conclusion

Management of unstable patients with ASR whilst taking a DOAC remains challenging. High degree of suspicion for splenic rupture in patients without trauma must be maintained. Computed tomography using intravenous contrast is the most sensitive and the most specified diagnostic tool. Emergent splenectomy in unstable patients will be lifesaving.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editor-in-chief of the journal on request.

Conflicts of interest disclosure

Not applicable.

Sources of funding

The authors did not receive any financial support for this report.

Author contributions

S.M.M.: gathering of data and writing the paper; A.Z.: supervision; S.H.M.: supervision; E.H.: supervision.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Seyed Mohammad Mozaffari.

Provenance and peer review

Not commissioned.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.