American Journal of Emergency Medicine 32 (2014) 1563.e1–1563.e3
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Spontaneous splenic artery aneurysm rupture: mimicking acute myocardial infarct Abstract Spontaneous splenic artery aneurysm (SAA) is a rare but a lifethreatening condition. Thus, early diagnoses may increase the chance of survival. A 52-year-old female patient was admitted to the emergency department with a pain that starts from the chest and epigastric region and radiates to back and left arm. The patient prediagnosed as having acute myocardial infarct and was under observation when acute abdomen and hemorrhagic shock developed. After further investigation, the patient was diagnosed as having SAA and has undergone a successful surgery. The patient was fully cured and discharged from the hospital on the seventh postoperative day. The patient originally presented with SAA, although she was primarily observed in the emergency department with acute myocardial infarct diagnosis because of similar symptoms and clinical findings to cardiovascular diseases. When changes in the clinical picture occurred, the patient was reevaluated and had undergone an operation because of SAA rupture. Therefore, physicians should take into consideration of aneurysm rupture in the differential diagnosis of the cardiovascular conditions; otherwise, the patient may lose his/her life. Visceral artery aneurysms are very rare conditions, and the most common one is spontaneous splenic artery aneurysm (SAA) [1]. Spontaneous rupture of these may cause serious life-threatening complications. Sometimes they cause more than 70% mortality [2]. Patients may present with a wide range of symptoms such as chest, upper abdomen, and back pain to shock; therefore, early diagnosis and therapy is very important in these cases [3]. In this article, we wanted to present an SAA spontaneous rupture case mimicking acute myocardial infarct (AMI), the process of diagnosis, and the emergency operation of the patient. A 52-year-old female patient was admitted to the emergency department with a pain that starts from the chest and epigastric region and radiates to back and left arm. She had a history of hypertension for a long time and has been taking lisinopril 10 mg/d. She had no other comorbidities or history of operation before. In her family history, she mentioned that she had lost her mother because of AMI. Blood pressure was 105/60 mm Hg; pulse rate, 100 beats/min; and oxygen saturation, 98%; other vital findings were normal. Twelvelead electrocardiogram (ECG) was performed and ST-segment depression was detected. Complete blood count, cardiac biomarkers, and blood chemistry panel was ordered. While waiting for the results of the laboratory tests, the patient was prediagnosed as having early AMI and taken under medical observation, and cardiology consultation was planned. She developed dyspnea; her pain increased and radiated to all quadrants of the abdomen while she was under observation. Her blood test results were as follows: white blood cell, 0735-6757/© 2014 Elsevier Inc. All rights reserved.
13 000/mm 3; hemoglobin level, 9.2 g/dL; hematocrit level, 38%; and platelet, 358 000/mm 3; other parameters were in the reference ranges. Because of the rapid decrease in blood pressure, the patient was consulted to our general surgery team. The patient was diagnosed as having acute abdomen and was in preshock state. Intravenous fluid therapy was increased, emergency abdominal ultrasound was performed, and massive hemoperitoneum was detected. Besides perihepatic, perisplenic, and pelvic massive hemorrhage, splenic artery aneurysm, measuring 7 × 6 × 4 cm, between the tail of pancreas and spleen, was also reported on abdominal computed tomographic (CT) scan (Figs. 1 and 2). The patient underwent emergency surgery. Laparotomy was performed. In the exploration, massive hemorrhage was observed in the abdomen. In further evaluation, the region between the tail of pancreas and spleen was explored, and active bleeding through SAA rupture, 7 cm in size, located in the distal part of splenic artery, was observed. Splenic artery was suspended. After proximal ligation of the SAA rupture site, splenectomy was performed (Figs. 3 and 4). A drain was placed in the region of the spleen. The operation then was terminated, and the patient remained in the intensive care unit postoperatively. A total of 4 U of fresh-frozen plasm and 3 U of erythrocyte suspension are given to the patient. Polyvalent pneumococcal and hemophilius influenza vaccine is administered postoperatively. The patient was fully cured and discharged from the hospital on the seventh postoperative day. The most common visceral artery aneurysm is SAA, causing serious life-threatening complications, and spontaneous rupture of SAA may cause more than 70% mortality [1,2]. It is very remarkable that most of the cases in the literature are female. Furthermore, rarely, SAA rupture can be detected in pregnant women and may be fatal [2]. Patients may present with a wide range of symptoms such as chest, upper abdomen, and back pain to shock; therefore, early diagnosis and therapy is crucial in these cases [3]. In this article, we wanted to present an SAA spontaneous rupture case mimicking AMI, the process of diagnosis, and the emergency operation of the patient. Because this situation is more common in women, gender may also be a risk factor for our patient. Increased portal hypertension is another risk factor, which can be seen mostly in cirrhosis, trauma, pregnancy, hypertension, and infective endocarditis [4]. Hypertension was the only comorbidity in our case, but it was under control with the medical treatment; thus, it cannot be a significant risk factor. In this case, becuse the patient administered to the ED with AMIlike symptoms and findings and had a family history of AMI, she was diagnosed as having AMI and all the other differential diagnoses were excluded. Intra-abdominal pathology was taken into consideration
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S. Zeren et al. / American Journal of Emergency Medicine 32 (2014) 1563.e1–1563.e3
Fig. 3. Postoperative image of splenic artery aneurysm. Fig. 1. Intravenous enhanced CT image showing perihepatic and perisplenic hemorrhage in the middle-distal part of splenic artery.
because of normal cardiac marker levels, hemodynamic instability, and onset of symptoms. The patient is consulted to the general surgery department shortly afterward. Thus, the patient with AMIlike clinical picture should be evaluated multiple times, and all the differential diagnoses should be excluded, even the ECG is supporting AMI diagnose. It should be kept in mind that SAA rupture may mimic the clinical symptoms and findings, even the laboratory test results and ECG, because the results can be devastating to the patient [5]. Clinical manifestations in these patients may vary from abdominal or chest pain to shock [6]. Rupture of the aneurysm directly into the abdomen is the main reason of shock, which may eventually leads to hypovolemia. Especially, risk of rupture is higher in aneurysms with the diameter greater than 2 cm [7]. The aneurysm of our patient has a diameter of 7 cm, which clearly leads to increased risk of rupture. Computed tomographic scan is a good method to diagnose SAA and the rupture of SAA, as the sensitivity and specifity are 94% and % 90, respectively [8,9]. However, we prefered abdominal ultrasound
Fig. 2. Intravenous enhanced CT image showing splenic artery aneurysm in the middledistal part of splenic artery.
because the patient's condition was not stable (preshock state and acute abdomen); prediagnosis was not consistent with the clinical findings, and the easiest diagnostic method was ultrasound in the emergency department. After detecting massive hemoperitoneum via ultrasound, CT scan was performed immediately. As it is known, SAA presence with trauma may increase spontaneous rupture risk [9]. In this case, differential diagnosis did not consist of SAA because SAA was occult and the patient had no trauma history. Various approaches exist if SAA is diagnosed in elective conditions, such as endovascular interventions and conventional and laparoscopic surgery [10,11]. However, like in this case, laparotomy is the convenient choice to treat the patient because the results may be fatal. Similar to this case, SAA is generally distally located [12]. Thus, splenic artery was ligated proximally and splenectomy was performed, and the patient's condition improved immediately after the operation. In patients with SAA, pseudoaneurysm, which is another pathology of the splenic artery and usually is seen after pancreatitis, should be taken into consideration in the differential diagnosis because the treament differs from SAA [13].
Fig. 4. Postoperative image of splenic artery aneurysm.
S. Zeren et al. / American Journal of Emergency Medicine 32 (2014) 1563.e1–1563.e3
Fatih Mehmet Ekici, MD Department of General Surgery Evliya Celebi Training and Research Hospital Kutahya, Turkey
Spontaneous rupture of SAA is a serious complication that may result in death. Thus, SAA rupture should be eliminated in patients presented with AMI-like symptoms and findings to increase the chance of survival by early diagnosis and intervention.
Sezgin Zeren, MD* Zülfü Bayhan, MD Department of General Surgery, Faculty of Medicine Dumlupinar University Kutahya, Turkey *Corresponding author. General Surgery, DPU Tip Fakultesi Genel Cerrahi AD, Evliya Celebi Kampusu 43100, Kutahya, Turkey E-mail address: [email protected] Yalcın Sönmez, MD Metin Mestan, MD Department of General Surgery Evliya Celebi Training and Research Hospital Kutahya, Turkey Mehmet Korkmaz, MD Department of Radiology Faculty of Medicine, Dumlupinar University Kutahya, Turkey Emine Kadıoglu, MD Department of Emergency Medicine Faculty of Medicine, Dumlupinar University Kutahya, Turkey Bercis Imge Ucar, MD Department of General Surgery Faculty of Medicine, Dumlupinar University Kutahya, Turkey Cigdem Devir, MD Department of Radiology Evliya Celebi Training and Research Hospital Kutahya, Turkey
1563.e3
Bekir Sanal, MD Department of Radiology Faculty of Medicine, Dumlupinar University Kutahya, Turkey http://dx.doi.org/10.1016/j.ajem.2014.07.011
References [1] Aybar MD, Barut AY, Öztürk A, Demirci İ, Tuzcu G. Splenik Arter Anevrizma Rüptürü. Istanbul Tip Dergisi 2009;3:92–5. [2] Pavlis T, Seretis C, Gourgiotis S, Aravosita P, Mystakelli C, Aloizos S. Spontaneous rupture of splenic artery aneurysm during the first trimester of pregnancy:report of an extremely rare case and review of the literature. Case Rep Obstet Gynecol 2012;2012:528051. [3] Liu CF, Kung CT, Liu BM, Ng SH, Huang CC, Ko SF. Splenic artery aneurysms encountered in the ED. Am J Emerg Med 2007;25(4):430–6. [4] Betal D, Khangura JS, Swan PJ, Mehmet V. Spontaneous ruptured splenic artery aneurysm: a case report. Cases J 2009;2:7150. http://dx.doi.org/10.1186/17571626-0002-0000007150. [5] Yadav S, Sharma P, Singh PK, Punia S, Desai P, Anjan AK, et al. Giant splenic artery aneurysm:a rare but potentially catastrophic surgical challenge. Int J Surg Case Rep 2012;3(11):533–6. http://dx.doi.org/10.1016/j.ijscr.2012.06.010. [6] Miao YD, Ye B. İntragastric rupture of splenic artery aneurysms: three case reports and literature review. Pak J Med Sci 2013;29(2):656–9. [7] Uyar İS, Okur FF, Akpınar B, Abacılar F, Yurtman V, Şahin V, et al. A giant splenic artery aneurysm: a case report. Türk Göğüs Kalp Damar Cerrahisi Dergisi 2013;21 (3):799–802. [8] Sakakibara K, Shindo S, Matsumoto M, Yoshida Y, Kimura M, Honda Y, et al. Splenic artery of the hepatosplenomesenteric trunk. Ann Vasc Dis 2013;6(4):730–3. http://dx.doi.org/10.3400/avd.cr.13-00057. [9] Khoshnevis J, Lotfollahzadeh S, Sobhiyeh MR, Najd Sepas H, Abbas Nejad M, Rahbari A, et al. Ruptured aneurysm of the splenic artery:a rare cause of abdominal pain after trauma. Trauma Mon 2013;18(1):46–9. http://dx.doi.org/10. 5812/traumamon.8271. [10] Kim Y, Johna S. Laparoscopic excision of splenic artery aneurysm. JSLS 2013;17(1): 132–4. http://dx.doi.org/10.4293/108680812X13517013317392. [11] Algudkar A. Unruptured splenic artery aneurysm presenting as epigastric pain. JRSM Short Rep 2010;1(3):24. http://dx.doi.org/10.1258/shorts.2010.010053. [12] Ali S, Verma V, Sastry R, Wani I. Giant splenic artery aneurysm: case report. ISRN Surg 2011;2011:383450. http://dx.doi.org/10.5402/2011/383450. [13] Gupta V, Kumar S, Kumar P, Chandra A. Giant pseudoaneurysm of the splenic artery. JOP 2011;12(2):190–3.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Spontaneous splenic artery aneurysm rupture: mimicking acute myocardial infarct Abstract Spontaneous splenic artery aneurysm (SAA) is a rare but a lifethreatening condition. Thus, early diagnoses may increase the chance of survival. A 52-year-old female patient was admitted to the emergency department with a pain that starts from the chest and epigastric region and radiates to back and left arm. The patient prediagnosed as having acute myocardial infarct and was under observation when acute abdomen and hemorrhagic shock developed. After further investigation, the patient was diagnosed as having SAA and has undergone a successful surgery. The patient was fully cured and discharged from the hospital on the seventh postoperative day. The patient originally presented with SAA, although she was primarily observed in the emergency department with acute myocardial infarct diagnosis because of similar symptoms and clinical findings to cardiovascular diseases. When changes in the clinical picture occurred, the patient was reevaluated and had undergone an operation because of SAA rupture. Therefore, physicians should take into consideration of aneurysm rupture in the differential diagnosis of the cardiovascular conditions; otherwise, the patient may lose his/her life. Visceral artery aneurysms are very rare conditions, and the most common one is spontaneous splenic artery aneurysm (SAA) [1]. Spontaneous rupture of these may cause serious life-threatening complications. Sometimes they cause more than 70% mortality [2]. Patients may present with a wide range of symptoms such as chest, upper abdomen, and back pain to shock; therefore, early diagnosis and therapy is very important in these cases [3]. In this article, we wanted to present an SAA spontaneous rupture case mimicking acute myocardial infarct (AMI), the process of diagnosis, and the emergency operation of the patient. A 52-year-old female patient was admitted to the emergency department with a pain that starts from the chest and epigastric region and radiates to back and left arm. She had a history of hypertension for a long time and has been taking lisinopril 10 mg/d. She had no other comorbidities or history of operation before. In her family history, she mentioned that she had lost her mother because of AMI. Blood pressure was 105/60 mm Hg; pulse rate, 100 beats/min; and oxygen saturation, 98%; other vital findings were normal. Twelvelead electrocardiogram (ECG) was performed and ST-segment depression was detected. Complete blood count, cardiac biomarkers, and blood chemistry panel was ordered. While waiting for the results of the laboratory tests, the patient was prediagnosed as having early AMI and taken under medical observation, and cardiology consultation was planned. She developed dyspnea; her pain increased and radiated to all quadrants of the abdomen while she was under observation. Her blood test results were as follows: white blood cell, 0735-6757/© 2014 Elsevier Inc. All rights reserved.
13 000/mm 3; hemoglobin level, 9.2 g/dL; hematocrit level, 38%; and platelet, 358 000/mm 3; other parameters were in the reference ranges. Because of the rapid decrease in blood pressure, the patient was consulted to our general surgery team. The patient was diagnosed as having acute abdomen and was in preshock state. Intravenous fluid therapy was increased, emergency abdominal ultrasound was performed, and massive hemoperitoneum was detected. Besides perihepatic, perisplenic, and pelvic massive hemorrhage, splenic artery aneurysm, measuring 7 × 6 × 4 cm, between the tail of pancreas and spleen, was also reported on abdominal computed tomographic (CT) scan (Figs. 1 and 2). The patient underwent emergency surgery. Laparotomy was performed. In the exploration, massive hemorrhage was observed in the abdomen. In further evaluation, the region between the tail of pancreas and spleen was explored, and active bleeding through SAA rupture, 7 cm in size, located in the distal part of splenic artery, was observed. Splenic artery was suspended. After proximal ligation of the SAA rupture site, splenectomy was performed (Figs. 3 and 4). A drain was placed in the region of the spleen. The operation then was terminated, and the patient remained in the intensive care unit postoperatively. A total of 4 U of fresh-frozen plasm and 3 U of erythrocyte suspension are given to the patient. Polyvalent pneumococcal and hemophilius influenza vaccine is administered postoperatively. The patient was fully cured and discharged from the hospital on the seventh postoperative day. The most common visceral artery aneurysm is SAA, causing serious life-threatening complications, and spontaneous rupture of SAA may cause more than 70% mortality [1,2]. It is very remarkable that most of the cases in the literature are female. Furthermore, rarely, SAA rupture can be detected in pregnant women and may be fatal [2]. Patients may present with a wide range of symptoms such as chest, upper abdomen, and back pain to shock; therefore, early diagnosis and therapy is crucial in these cases [3]. In this article, we wanted to present an SAA spontaneous rupture case mimicking AMI, the process of diagnosis, and the emergency operation of the patient. Because this situation is more common in women, gender may also be a risk factor for our patient. Increased portal hypertension is another risk factor, which can be seen mostly in cirrhosis, trauma, pregnancy, hypertension, and infective endocarditis [4]. Hypertension was the only comorbidity in our case, but it was under control with the medical treatment; thus, it cannot be a significant risk factor. In this case, becuse the patient administered to the ED with AMIlike symptoms and findings and had a family history of AMI, she was diagnosed as having AMI and all the other differential diagnoses were excluded. Intra-abdominal pathology was taken into consideration
1563.e2
S. Zeren et al. / American Journal of Emergency Medicine 32 (2014) 1563.e1–1563.e3
Fig. 3. Postoperative image of splenic artery aneurysm. Fig. 1. Intravenous enhanced CT image showing perihepatic and perisplenic hemorrhage in the middle-distal part of splenic artery.
because of normal cardiac marker levels, hemodynamic instability, and onset of symptoms. The patient is consulted to the general surgery department shortly afterward. Thus, the patient with AMIlike clinical picture should be evaluated multiple times, and all the differential diagnoses should be excluded, even the ECG is supporting AMI diagnose. It should be kept in mind that SAA rupture may mimic the clinical symptoms and findings, even the laboratory test results and ECG, because the results can be devastating to the patient [5]. Clinical manifestations in these patients may vary from abdominal or chest pain to shock [6]. Rupture of the aneurysm directly into the abdomen is the main reason of shock, which may eventually leads to hypovolemia. Especially, risk of rupture is higher in aneurysms with the diameter greater than 2 cm [7]. The aneurysm of our patient has a diameter of 7 cm, which clearly leads to increased risk of rupture. Computed tomographic scan is a good method to diagnose SAA and the rupture of SAA, as the sensitivity and specifity are 94% and % 90, respectively [8,9]. However, we prefered abdominal ultrasound
Fig. 2. Intravenous enhanced CT image showing splenic artery aneurysm in the middledistal part of splenic artery.
because the patient's condition was not stable (preshock state and acute abdomen); prediagnosis was not consistent with the clinical findings, and the easiest diagnostic method was ultrasound in the emergency department. After detecting massive hemoperitoneum via ultrasound, CT scan was performed immediately. As it is known, SAA presence with trauma may increase spontaneous rupture risk [9]. In this case, differential diagnosis did not consist of SAA because SAA was occult and the patient had no trauma history. Various approaches exist if SAA is diagnosed in elective conditions, such as endovascular interventions and conventional and laparoscopic surgery [10,11]. However, like in this case, laparotomy is the convenient choice to treat the patient because the results may be fatal. Similar to this case, SAA is generally distally located [12]. Thus, splenic artery was ligated proximally and splenectomy was performed, and the patient's condition improved immediately after the operation. In patients with SAA, pseudoaneurysm, which is another pathology of the splenic artery and usually is seen after pancreatitis, should be taken into consideration in the differential diagnosis because the treament differs from SAA [13].
Fig. 4. Postoperative image of splenic artery aneurysm.
S. Zeren et al. / American Journal of Emergency Medicine 32 (2014) 1563.e1–1563.e3
Fatih Mehmet Ekici, MD Department of General Surgery Evliya Celebi Training and Research Hospital Kutahya, Turkey
Spontaneous rupture of SAA is a serious complication that may result in death. Thus, SAA rupture should be eliminated in patients presented with AMI-like symptoms and findings to increase the chance of survival by early diagnosis and intervention.
Sezgin Zeren, MD* Zülfü Bayhan, MD Department of General Surgery, Faculty of Medicine Dumlupinar University Kutahya, Turkey *Corresponding author. General Surgery, DPU Tip Fakultesi Genel Cerrahi AD, Evliya Celebi Kampusu 43100, Kutahya, Turkey E-mail address: [email protected] Yalcın Sönmez, MD Metin Mestan, MD Department of General Surgery Evliya Celebi Training and Research Hospital Kutahya, Turkey Mehmet Korkmaz, MD Department of Radiology Faculty of Medicine, Dumlupinar University Kutahya, Turkey Emine Kadıoglu, MD Department of Emergency Medicine Faculty of Medicine, Dumlupinar University Kutahya, Turkey Bercis Imge Ucar, MD Department of General Surgery Faculty of Medicine, Dumlupinar University Kutahya, Turkey Cigdem Devir, MD Department of Radiology Evliya Celebi Training and Research Hospital Kutahya, Turkey
1563.e3
Bekir Sanal, MD Department of Radiology Faculty of Medicine, Dumlupinar University Kutahya, Turkey http://dx.doi.org/10.1016/j.ajem.2014.07.011
References [1] Aybar MD, Barut AY, Öztürk A, Demirci İ, Tuzcu G. Splenik Arter Anevrizma Rüptürü. Istanbul Tip Dergisi 2009;3:92–5. [2] Pavlis T, Seretis C, Gourgiotis S, Aravosita P, Mystakelli C, Aloizos S. Spontaneous rupture of splenic artery aneurysm during the first trimester of pregnancy:report of an extremely rare case and review of the literature. Case Rep Obstet Gynecol 2012;2012:528051. [3] Liu CF, Kung CT, Liu BM, Ng SH, Huang CC, Ko SF. Splenic artery aneurysms encountered in the ED. Am J Emerg Med 2007;25(4):430–6. [4] Betal D, Khangura JS, Swan PJ, Mehmet V. Spontaneous ruptured splenic artery aneurysm: a case report. Cases J 2009;2:7150. http://dx.doi.org/10.1186/17571626-0002-0000007150. [5] Yadav S, Sharma P, Singh PK, Punia S, Desai P, Anjan AK, et al. Giant splenic artery aneurysm:a rare but potentially catastrophic surgical challenge. Int J Surg Case Rep 2012;3(11):533–6. http://dx.doi.org/10.1016/j.ijscr.2012.06.010. [6] Miao YD, Ye B. İntragastric rupture of splenic artery aneurysms: three case reports and literature review. Pak J Med Sci 2013;29(2):656–9. [7] Uyar İS, Okur FF, Akpınar B, Abacılar F, Yurtman V, Şahin V, et al. A giant splenic artery aneurysm: a case report. Türk Göğüs Kalp Damar Cerrahisi Dergisi 2013;21 (3):799–802. [8] Sakakibara K, Shindo S, Matsumoto M, Yoshida Y, Kimura M, Honda Y, et al. Splenic artery of the hepatosplenomesenteric trunk. Ann Vasc Dis 2013;6(4):730–3. http://dx.doi.org/10.3400/avd.cr.13-00057. [9] Khoshnevis J, Lotfollahzadeh S, Sobhiyeh MR, Najd Sepas H, Abbas Nejad M, Rahbari A, et al. Ruptured aneurysm of the splenic artery:a rare cause of abdominal pain after trauma. Trauma Mon 2013;18(1):46–9. http://dx.doi.org/10. 5812/traumamon.8271. [10] Kim Y, Johna S. Laparoscopic excision of splenic artery aneurysm. JSLS 2013;17(1): 132–4. http://dx.doi.org/10.4293/108680812X13517013317392. [11] Algudkar A. Unruptured splenic artery aneurysm presenting as epigastric pain. JRSM Short Rep 2010;1(3):24. http://dx.doi.org/10.1258/shorts.2010.010053. [12] Ali S, Verma V, Sastry R, Wani I. Giant splenic artery aneurysm: case report. ISRN Surg 2011;2011:383450. http://dx.doi.org/10.5402/2011/383450. [13] Gupta V, Kumar S, Kumar P, Chandra A. Giant pseudoaneurysm of the splenic artery. JOP 2011;12(2):190–3.
