Fig. 2
From: Atraumatic splenic rupture, an underrated cause of acute abdomen
An elderly 89-year-old male with chronic heart failure, previous transurethral resection of non-muscle-invasive urinary bladder carcinoma, and lung emphysema experienced sudden hypotension and fainting. He was not on anticoagulants. Physical findings included palpation tenderness in the left hemiabdomen, tachycardia, and hypotension. Laboratory tests revealed severe blood loss: haemoglobin dropped from 9.2 to 6.4 g/dl within four hours. Platelet count, prothrombin time, and activated partial thromboplastin time were within normal range. Urgent CT including unenhanced (a), arterial- (b, c) and venous-phase (d, e) post-contrast images revealed mixed attenuation peritoneal effusion (+) consistent with haemoperitoneum. The spleen was surrounded, medially dislocated, and compressed by massive, fresh hyperattenuating (up to 55 Hounsfield units), partly subcapsular haemorrhage (*). Pseudoaneurysms and active bleeding were not seen. The spleen showed homogeneous parenchymal enhancement without focal lesions or signs of diffuse infiltrating disease. Retrospectively, contrast-enhanced CT obtained four months earlier (F) for bladder cancer staging revealed a normal, homogeneous spleen. The patient underwent urgent splenectomy and eventually recovered. Surgical pathology revealed medium-sized spleen with reactive lymphoid hyperplasia, and excluded acute infectious or neoplastic changes. Final diagnosis was idiopathic splenic rupture