Ruptured true aneurysm of the splenic artery: an unusual cause of haemoperitoneum.AA Deshpande, VM Kulkarni, S Rege, AN Dalvi, JV Hardikar
Departments of Gastroenterology Surgical Service and General Surgery, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumba-400 012, India., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 11298470
Source of Support: None, Conflict of Interest: None
True aneurysm of the splenic artery is rare. Two cases of ruptured true splenic artery aneurysms are presented. The first patient was a 62-year-old female who presented within 6 hours of the onset of symptoms. The other was a 27-year-old non-alcoholic male patient who was admitted in a state of shock after 2 days of observation in a peripheral hospital. Both patients had haemoperitoneum and were subjected to exploratory laparotomy. Aneurysmectomy was performed in both the patients in addition to left splenopancreatectomy in the first case and splenectomy in the second. However, due to the prolonged preoperative shock, the second patient succumbed on the third postoperative day.
Keywords: Abdomen, Acute, diagnosis,Adult, Aneurysm, complications,diagnosis,surgery,Aneurysm, Ruptured, complications,diagnosis,Case Report, Emergency Treatment, methods,Female, Follow-Up Studies, Hemoperitoneum, diagnosis,etiology,surgery,Human, Laparotomy, Male, Middle Age, Splenic Artery,
True aneurysm of the splenic artery is the third most common intraabdominal aneurysm following infra-renal aorta and the iliac arteries and the commonest splanchnic artery aneurysm. Asymptomatic splenic artery aneurysm (SAA) is now diagnosed more frequently due to advances in imaging modalities. Rupture of SAA is rare but can be fatal if there is delay in the diagnosis and treatment. This fact has generated continuing interest in the aetiology, natural history and management of these aneurysms.,,,, Awareness of this condition and aggressive surgical treatment can be life-saving., Two cases of ruptured SAA are presented here.
A 62-year-old multipara female presented with pain in the epigastrium and left hypochondrium of 10 hours duration. There was no other symptom or past history of pain. On examination the patient was pale with a rapid thready pulse, systolic blood pressure of 80 mm Hg and cold and clammy extremities. Abdomen was distended and diagnostic peritoneal tap revealed haemoperitoneum. Exploratory laparotomy was carried out after haemodynamically stabilising the patient. There was one litre of blood in the free peritoneal cavity and the lesser sac was full of blood. On opening the lesser sac and evacuating the haematoma, the source of bleeding was identified as the proximal end of a ruptured splenic artery aneurysm involving the dital third portion. Proximal ligation with aneurysmectomy and left splenopancreatectomy was carried out. There was no evidence of chronic pancreatitis or portal hypertension. The postoperative course was uneventful and the patient was discharged on the 12th postoperative day. She continues to do well four months later. Histopathology revealed a 2 centimetre diameter ruptured true aneurysm of the splenic artery with a single atheromatous plaque at one site within the aneurysm [Figure - 1]. The proximal and distal vessels were normal.
A 27-year-old nonalcoholic male with sudden onset upper abdominal pain for two days had a sudden unexplained cardiovascular collapse. At admission the pulse rate was 120/minute, systolic blood pressure was 70 mm of Hg and the patient was pale. Abdomen was distended with presence of free fluid and paracentesis revealed fresh blood. Emergency exploratory laparotomy after attempting to correct shock revealed a ruptured distal third splenic artery aneurysm measuring two centimetre. Aneurysmectomy with splenectomy was carried out. Postoperatively, the patient developed renal failure and died on the third postoperative day in spite of haemodialysis and supportive care. Histopathology revealed a true splenic artery aneurysm without any aetiology.
The true incidence of SAA is difficult to determine as majority of these aneurysms are asymptomatic. Reported incidence of SAA in various autopsy series ranges from 0.01% in unselected groups to as high as 10.4% in high risk populations.,
True aneurysms of the splenic artery are distinct from pseudoaneurysms. The latter are formed due to inflammation and destruction of the whole arterial wall following pancreatitis, septic emboli or arteritis., The aetiology of true SAA is obscure. Atherosclerosis and congenital defects of the arterial wall has been described as the major causes of SAA, whereas others claim that atherosclerosis is a secondary event in SAA. Preliminary weakness of the arterial wall with concomitant increase in blood pressure is considered to promote aneurysm formation. Liver diseases with splenomegaly, repeated pregnancies, systemic hypertension and old age are certain clinical settings with a high incidence of SAA.
The exact incidence of rupture of SAA is not known. As the diagnosis of asymptomatic SAA rises due to newer investigative modalities, there has been a reported decline in the rate of rupture in various series from 3-46%.,, Though frequency of SAA increases with age, rupture may occur at any age.,
Certain factors are associated with an increased risk of rupture viz. pregnancy, expanding aneurysm, aneurysm of more than two centimeters in diameter, portal hypertension with liver transplant or portacaval shunt. Various series have tried to follow the natural history of SAA with average aneurysm size varying from 1.8 to 2.5 centimeters, and found no ruptures. Though size more than 2 centimetres is generally is an indication for prophylactic treatment, the exact size at which rupture is likely to occur is difficult to determine.
A double rupture phenomenon has been described in the clinical course of a ruptured SAA. Initially the bleeding remains confined in the lesser sac, followed 6-96 hours later by free intrapentoneal haemorrhage and collapse. The initial phase where haemorrhage remains confined to the lesser sac may provide vital time for diagnosis and preparation for intervention. Contrast enhanced computerised tomography will give a diagnosis in majority of the patients but an angiogram is the investigation of choice.
Management of ruptured SAA requires awareness and aggressive surgical approach. Aneurysmectomy with splenectomy or left splenopancreatectomy, ligation of the proximal and distal splenic artery and aneurysmectomy for distal, mid and proximal third SAA respectively are the procedures described., Splenic conservation is desirable but is difficult in emergency setting with ruptured SAA. Angiography and embolisation has been described for pseudoaneurysms and for unruptured true aneurysms.
[Figure - 1]