Conservatively Managed Spontaneous Splenic Rupture in a Hemodialysis Patient

Dear Editor,

A 68-year-old diabetic male with 8-year dialysis vintage reported to the emergency room in March 2023, with 4 days of pain in the left hypochondrium, radiating to the left shoulder (Kehr’s sign). He was anxious, had a BP of 100/70 mm Hg and a pulse of 96 beats/min. Examination showed tenderness and guarding in the left hypochondrium. His hemoglobin was 9.6 g/dL, and total leucocyte and platelet counts were 13900/mm³ and 234000/mm³, respectively. Ultrasound suggested and CT confirmed class 3 tear (moderate-severe) with hematoma in the spleen [Figure 1]. Other investigative work-up was negative. In view of hemodynamic stability, he was managed conservatively with bed rest, avoidance of anticoagulants (during hemodialysis), and anti-platelet drugs. Ambulation began after a week, and heparin was reintroduced. The patient made an uneventful recovery.

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Figure 1:

Computed tomography scan showing a class 3 splenic tear with a hematoma.

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Splenic tears usually occur due to road traffic accidents or trauma. Spontaneous splenic rupture (SSR) is rarely reported. Liu et al. found 8 SSR cases (3.2%) in a series of 251 cases of spleen rupture.¹ While analyzing 848 SSR cases over 28 years, Renzulli et al.² found underlying neoplasm (30.3%), infections (27.3%), non-infectious causes (20.0%), and drug/treatment-related (6.8%) causes as possible risk factors. Management included splenectomy in 84.1% of cases. As per the American Association for Surgery of Trauma (AAST) classification, our patient had moderate- severe injury.³

There are < 15 SSR reports in dialysis patients; all underwent splenectomy.^4,5 There are no management guidelines for SSR. Our patient is the first case to be successfully managed conservatively. Uremic coagulopathy, anti-platelet drugs, and anticoagulants are possible risk factors in such patients. This report conveys two messages. First, the SSR presentation in patients on dialysis can be subacute, and second, in hemodynamically stable patients, conservative management can be considered even in severe injury.