Spontaneous Rupture An Unusual M.
Complication
Tanju Soyer, MD; Daniel
E.
of
of the
Anticoagulant Therapy
Merck, MD; Joaquin S. Aldrete,
MD
\s=b\ A 44-year-old man, who had been taking warfarin sodium because of a previous myocardial infarct, suddenly developed abdominal pain and signs of peritoneal irritation, requiring exploratory laparotomy. The spleen was ruptured. There were not any systemic diseases nor antecedents of trauma that could be considered predisposing factors for the apparently spontaneous rupture of the spleen. The only abnormality recorded was an elevated prothrombin time. Thus, a coagulopathy produced by the anticoagulants appeared to be the only possible predisposing factor for his splenic rupture.
(Arch Surg 111:610, 1976) of the number of unrelated Seltzer and
Spleen
has been described in
rupture spleen SpontaneousQuarantinodiseases, including hemophilia.1 reported a
such an occurrence in a because of pulmonary embolism. This report describes the case of a patient, receiving oral anticoagulant therapy, whose spleen
patient receiving anticoagulants ruptured spontaneously.
of the abdomen, with voluntary rigidity of the muscles of the abdominal wall. The bowel sounds were hyperactive. The hematocrit reading, white blood cell count, and levels of serum amylase, blood electrolytes, blood urea nitrogen, creatinine, alkaline phosphatase, and bilirubin were all within normal limits. Other laboratory values obtained were as follows: serum glutamic oxaloacetic transaminase, 75 ImU/ml; lactic dehydrogenase, 235 ImTJ/ml; creatine phosphokinase, 680 ImU/ml; and prothrombin time, 58 seconds (6.2%), with control of 12.5 seconds (100%). The urinalysis showed microscopic hematuria. There were no signifi¬ cant electrocardiographic changes. Roentgenograms of the chest and abdomen were unremarkable. An intravenous pyelogram showed a prominent splenic shadow. A paracentesis was performed, and 30 ml of blood were aspi¬ were rated from the peritoneal cavity. After 20 mg of vitamin given intravenously, an emergency exploratory laparotomy showed a large amount of free blood in the abdomen; the site of bleeding was located in the superior pole of the spleen, which had a tear approximately 10 cm long. The spleen was removed. By examination, it was grossly and microscopically normal except for the site of rupture. The patient recovered uneventfully.
REPORT OF A CASE
COMMENT
A 44-year-old man was admitted to the emergency room because of discomfort, of 12 hours' duration, in the left upper quadrant of his abdomen, which had progressed to severe epigastric and left upper abdominal pain radiating to the left shoulder, associated with vomiting and diarrhea. Seven months prior to his illness, because of a demonstrated myocardial infarct, he was instructed to take daily 10 mg of warfarin sodium (Coumadin). He denied having had any abdominal trauma. At examination, his skin was cold and clammy, the pulse rate was 100 beats per minute, and blood pressure was 110/70 mm Hg. There was tenderness in the epigastrium and left upper quadrant
This patient did not have any systemic disease. He denied having any trauma that could be associated with the splenic rupture. Except for the extremely prolonged prothrombin time, related to anticoagulant treatment, all laboratory test results were within normal limits. There¬ fore, faulty coagulation appeared to be the only predis¬ posing factor for his splenic rupture. Spontaneous rupture of the spleen is a very rare entity, but if unrecognized and untreated, the outcome is usually fatal. Thus, when a patient receiving anticoagulant treat¬ ment suddenly develops abdominal pain and signs of intraabdominal bleeding, this possibility should be considered. References
Accepted for publication
Jan 7, 1976. From the Department of Surgery, University of Alabama School of Medicine and Baptist Medical Centers, Birmingham. Reprint requests to Department of Surgery, University of Alabama School of Medicine, University Station, Birmingham, AL 35294 (Dr
Soyer).
1. Brook
J, Newman PE: Spontaneous rupture of the spleen in hemoArch Intern Med 115:595-597, 1965. 2. Seltzer MH, Quarantillo EP Jr: Spontaneous splenic rupture in an anticoagulated patient: A case report. J Med Soc NJ 70:397-398, 1973.
philia.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pittsburgh User on 06/20/2015
Complication
Tanju Soyer, MD; Daniel
E.
of
of the
Anticoagulant Therapy
Merck, MD; Joaquin S. Aldrete,
MD
\s=b\ A 44-year-old man, who had been taking warfarin sodium because of a previous myocardial infarct, suddenly developed abdominal pain and signs of peritoneal irritation, requiring exploratory laparotomy. The spleen was ruptured. There were not any systemic diseases nor antecedents of trauma that could be considered predisposing factors for the apparently spontaneous rupture of the spleen. The only abnormality recorded was an elevated prothrombin time. Thus, a coagulopathy produced by the anticoagulants appeared to be the only possible predisposing factor for his splenic rupture.
(Arch Surg 111:610, 1976) of the number of unrelated Seltzer and
Spleen
has been described in
rupture spleen SpontaneousQuarantinodiseases, including hemophilia.1 reported a
such an occurrence in a because of pulmonary embolism. This report describes the case of a patient, receiving oral anticoagulant therapy, whose spleen
patient receiving anticoagulants ruptured spontaneously.
of the abdomen, with voluntary rigidity of the muscles of the abdominal wall. The bowel sounds were hyperactive. The hematocrit reading, white blood cell count, and levels of serum amylase, blood electrolytes, blood urea nitrogen, creatinine, alkaline phosphatase, and bilirubin were all within normal limits. Other laboratory values obtained were as follows: serum glutamic oxaloacetic transaminase, 75 ImU/ml; lactic dehydrogenase, 235 ImTJ/ml; creatine phosphokinase, 680 ImU/ml; and prothrombin time, 58 seconds (6.2%), with control of 12.5 seconds (100%). The urinalysis showed microscopic hematuria. There were no signifi¬ cant electrocardiographic changes. Roentgenograms of the chest and abdomen were unremarkable. An intravenous pyelogram showed a prominent splenic shadow. A paracentesis was performed, and 30 ml of blood were aspi¬ were rated from the peritoneal cavity. After 20 mg of vitamin given intravenously, an emergency exploratory laparotomy showed a large amount of free blood in the abdomen; the site of bleeding was located in the superior pole of the spleen, which had a tear approximately 10 cm long. The spleen was removed. By examination, it was grossly and microscopically normal except for the site of rupture. The patient recovered uneventfully.
REPORT OF A CASE
COMMENT
A 44-year-old man was admitted to the emergency room because of discomfort, of 12 hours' duration, in the left upper quadrant of his abdomen, which had progressed to severe epigastric and left upper abdominal pain radiating to the left shoulder, associated with vomiting and diarrhea. Seven months prior to his illness, because of a demonstrated myocardial infarct, he was instructed to take daily 10 mg of warfarin sodium (Coumadin). He denied having had any abdominal trauma. At examination, his skin was cold and clammy, the pulse rate was 100 beats per minute, and blood pressure was 110/70 mm Hg. There was tenderness in the epigastrium and left upper quadrant
This patient did not have any systemic disease. He denied having any trauma that could be associated with the splenic rupture. Except for the extremely prolonged prothrombin time, related to anticoagulant treatment, all laboratory test results were within normal limits. There¬ fore, faulty coagulation appeared to be the only predis¬ posing factor for his splenic rupture. Spontaneous rupture of the spleen is a very rare entity, but if unrecognized and untreated, the outcome is usually fatal. Thus, when a patient receiving anticoagulant treat¬ ment suddenly develops abdominal pain and signs of intraabdominal bleeding, this possibility should be considered. References
Accepted for publication
Jan 7, 1976. From the Department of Surgery, University of Alabama School of Medicine and Baptist Medical Centers, Birmingham. Reprint requests to Department of Surgery, University of Alabama School of Medicine, University Station, Birmingham, AL 35294 (Dr
Soyer).
1. Brook
J, Newman PE: Spontaneous rupture of the spleen in hemoArch Intern Med 115:595-597, 1965. 2. Seltzer MH, Quarantillo EP Jr: Spontaneous splenic rupture in an anticoagulated patient: A case report. J Med Soc NJ 70:397-398, 1973.
philia.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pittsburgh User on 06/20/2015
