Spontaneous Splenic Rupture Following Bouts of Coughing
Splenic rupture due to trauma is relatively common. However, spontaneous non-traumatic ruptures do occur. Causes include infection, neoplasia and infiltrative process. The following case report has been published in the Journal of Current Surgery.

A 59-year-old female presented with dyspnea and left upper abdominal discomfort following bouts of coughing, and was provisionally diagnosed as pulmonary embolism. CT scans of the chest and abdomen were conducted. Her workup for pulmonary embolus was negative; the heart was normal in size and the descending aorta and main pulmonary artery were not enlarged; however, there was presence of centrilobular emphysema and mucus plugging in both lower lobes.

CT revealed incidental finding of a large heterogenous perisplenic collection consistent with a hematoma and hemoperitoneum layering in the pelvis. Acute care surgery was consulted. An open splenectomy was performed. An upper midline incision was made from the xiphisternum to the umbilicus. The peritoneal cavity was entered. A Bookwalter was used for exposure. The spleen had already ruptured. A ligature was used to divide the omentum and fat and the gastrosplenic omentum. Lap pads were placed behind the spleen to elevate and medialize the spleen into the midline operative field. The surgeon’s left hand was passed laterally to the spleen, bluntly dissecting the splenophrenic and splenorenal ligaments, and mobilizing the spleen anteromedially into the wound.

With the spleen fully mobilized, the splenic vessels were taken between clamps and ligated. The artery was always ligated before the vein. Any remaining short gastric vessels or other attachments were divided, freeing the spleen from the abdomen. Once the spleen was out, attention was placed to accessory spleen remnants. There were isolated pockets in the splenorenal ligament which were taken out by blunt dissection.

The wound bed was thoroughly irrigated with warm saline till the return was clear. Fibrillar and avitene local hemostatic agents were placed in the splenic bed. The abdomen was closed in layers with 1-0 maxon for fascia followed by 3-0 vicryl for subcutaneous and the skin was closed with staples. The patient tolerated the surgery well.

Only a few case reports are published documenting spontaneous splenic rupture following coughing. The therapy of choice can vary between patients depending on the grade of splenic rupture, hemodynamic instability, availability of endovascular treatment and physician preference.

Treatment should be focused on preserving splenic tissue if feasible. Non-traumatic rupture of the spleen must be considered in patients presenting with left-sided upper abdominal pain even without evident history of trauma, since early recognition and treatment can prevent serious morbidity and mortality.

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