Correspondence

Spontaneous Rupture of a Nontraumatic Intrasplenic Aneurysm

N Engl J Med 2000; 342:1999-2000June 29, 2000

Article

To the Editor:

Spontaneous rupture of splenic lesions is a well-described complication of infectious, hematologic, and neoplastic diseases.1 Intrasplenic aneurysms are uncommon and have been found most frequently in patients with portal hypertension.

We recently cared for a 36-year-old man who presented to a local hospital with acute, severe, diffuse abdominal pain and pain in the left shoulder. Initial examination revealed hypotension, tachycardia, and diffuse abdominal pain on palpation, with rebound tenderness. The patient's initial hemoglobin concentration was 6.7 g per deciliter, for which he was given two units of packed red cells, after which his blood pressure and hemoglobin concentration increased. Computed tomography of the abdomen showed a splenic hematoma and intraperitoneal fluid consistent with the appearance of blood. During the next 48 hours, the hemoglobin concentration remained stable and the abdominal pain subsided; the patient was then sent home.

The patient came to our clinic four months later with increasing upper abdominal fullness, bloating, and early satiety. He had no history of abdominal trauma, weight loss, or bleeding abnormalities. Physical examination revealed a healthy, well-nourished man. His abdomen was soft and flat. No masses were palpable. Repeated abdominal computed tomography revealed a 10-cm mass arising from the superior pole of the spleen (Figure 1AFigure 1Computed Tomographic Scan of a Mass in the Upper Abdomen (Panel A) and Photograph of the Resected Spleen, Showing a Ruptured Intrasplenic Aneurysm (Panel B).).

The patient underwent laparotomy, which revealed a 10-cm fluctuant, round mass in the superior aspect of the spleen. The liver was normal, and there was no evidence of portal hypertension. Splenectomy was performed, and the patient had an uneventful postoperative course. At the six-month follow-up visit, he had no symptoms.

Gross pathological evaluation showed a 470-g spleen with a round, well-encapsulated mass that was filled with clotted blood (Figure 1B). The cut surface was smooth and shiny. The mass arose from the splenic parenchyma and communicated with the arterial vasculature. Histopathological evaluation with elastin staining of representative sections of the mass revealed disorganization of the elastic membrane, with focal fragmentation of the wall, establishing the diagnosis of an intrasplenic aneurysm.

Patients with splenic rupture typically present with abdominal pain, usually in the left upper quadrant; left-shoulder pain (Kehr's sign); shock; back pain; and symptoms related to infection.2,3 These findings can be confused with those of pulmonary embolism, myocardial infarction, or other intraabdominal emergencies.

Unlike extraparenchymal splenic-artery aneurysms, intrasplenic aneurysms are not usually calcified. Atherosclerosis has been implicated as a cause of extrasplenic splenic-artery aneurysms; however, intrasplenic arterial aneurysms are typically unrelated to atherosclerotic disease.4

T. Christopher Windham, M.D.
Semyon A. Risin, M.D.
Eric P. Tamm, M.D.
University of Texas–Houston, Houston, TX 77030

4 References

1. 1

   Feist JH, Gajaraj A. Extra- and intrasplenic artery aneurysms in portal hypertension. Radiology 1977;125:331-334
   Web of Science | Medline

2. 2

   Lieberman ME, Levitt MA. Spontaneous rupture of the spleen: a case report and literature review. Am J Emerg Med 1989;7:28-31
   CrossRef | Web of Science | Medline

3. 3

   Zingman BS, Viner BL. Splenic complications in malaria: case report and review. Clin Infect Dis 1993;16:223-232
   CrossRef | Web of Science | Medline

4. 4

   Reuter SR, Redman HC. Intrasplenic arterial aneurysms. J Can Assoc Radiol 1968;19:200-202
   Medline

Citing Articles (5)

Citing Articles

1. 1

   Toru Obuchi, Akira Sasaki, Jun Nakajima, Hiroyuki Nitta, Koki Otsuka, Go Wakabayashi. (2009) Laparoscopic Surgery for Splenic Artery Aneurysm. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 19:4, 338-340
   CrossRef

2. 2

   Romaric Loffroy, Boris Guiu, Jean-Pierre Cercueil, Côme Lepage, Nicolas Cheynel, Eric Steinmetz, Frédéric Ricolfi, Denis Krausé. (2008) Embolisation artérielle par cathéter des anévrismes et des faux-anévrismes de l'artère splénique: résultats à court et long terme. Annales de Chirurgie Vasculaire 22:5, 672-680
   CrossRef

3. 3

   Romaric Loffroy, Boris Guiu, Jean-Pierre Cercueil, Côme Lepage, Nicolas Cheynel, Eric Steinmetz, Frédéric Ricolfi, Denis Krausé. (2008) Transcatheter Arterial Embolization of Splenic Artery Aneurysms and Pseudoaneurysms: Short- and Long-Term Results. Annals of Vascular Surgery 22:5, 618-626
   CrossRef

4. 4

   E. Peña Fernández, R. de la Cruz Burgos, J.V. del Cerro González, M. Rebollo Polo. (2007) Rotura de bazo espontánea secundaria a aneurisma intraesplénico. Radiología 49:6, 424-426
   CrossRef

5. 5

   Christian Grg, Julia Clle, Mathias Wied, Wolf B. Schwerk, Gerhard Zugmaier. (2003) Spontaneous nontraumatic intrasplenic pseudoaneurysm: Causes, sonographic diagnosis, and prognosis. Journal of Clinical Ultrasound 31:3, 129-134
   CrossRef