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• W2406384934 abstract "Dear Sir, We recently read with interest the pictorial review of splenic emergencies by Unal et al., just published in Insights into Imaging. After describing the common injuries from blunt abdominal trauma, this paper comprehensively describes several more or less unusual non-traumatic acute conditions including splenic infarction, aneurysms and pseudoaneurysms, arterial and venous thrombosis, splenic torsion, sequestration in sickle-cell anaemia, infections, and abscesses, with an appropriate emphasis on the mainstay role of multidetector computed tomography (CT) [1]. On the basis of our personal experience, we strongly agree with the Authors when they state that the spleen is an underrated cause of acute abdomen, and that severe morbidity and mortality result from delayed or missed diagnosis of splenic lesions. However, upon finishing reading the article we thought that general radiologists should be well aware of the condition known as life-threatening atraumatic splenic rupture (ASR), which has not yet been presented [1–3]. ASR is uncommon but not exceptional: in fact, searching the English-language literature using PubMed yields more than a thousand publications, over 300 in the last ten years, the vast majority being case reports. The incidence, mechanisms, treatment guidelines, and prognosis are poorly defined due to heterogeneity and limited availability of comprehensive reviews. ASR may occur in a wide age range, from teenagers and young people (particularly from infectious causes) to the elderly. The predominant manifestations include variable degrees of upper or left-sided abdominal pain, tachycardia, and hypotension, followed at a later stage by malaise, vomiting, generalised abdominal tenderness and peritonism, and progressive haemodynamic shock [4–8]. The vast majority (over 90 %) of cases are “pathologic” ASRs, which develop in a diseased spleen from the ample but specific range of disorders listed in Table 1. Infections, coagulopathy, and neoplasms represent the three major aetiologic groups. Interestingly, a recent review of 613 cases disclosed that ASR represents the initial manifestation of the previously unknown underlying disease in over 50 % of patients [7, 8]. Alternatively, “idiopathic” ASR occasionally occurs in a normal-appearing spleen without predisposing factors [4–8]. Due to its prevalence, malaria (particularly from Plasmodium vivax infection) represents the single major cause of ASR worldwide. Due to tourism, migrations, and drug resistance, malaria is increasingly encountered even outside tropical-subtropical Asia and Africa and the endemic American regions. In Western countries, malarial ASR should be suspected in non-immune returning travelers, expatriates, or recent immigrants from endemic places—even despite appropriate prophylaxis or during antimalarial therapy—and is associated with a non-negligible mortality (22 %) [9, 10]. In the setting of suspected or proven malaria, cross-sectional imaging with CT allows differentiation of the common splenic infarction from rupture, since the latter may require immediate or delayed splenectomy [11]. During the last eight years at our two hospitals we encountered at least 12 cases of ASR, half of them secondary to anticoagulation (Fig. 1). In the literature, drug-related cases account for up to one-third (9-33 %) of ASRs. In the anticoagulated population, splenic bleeding is a rare * Massimo Tonolini mtonolini@sirm.org" @default.
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• W2406384934 date "2016-05-18" @default.
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• W2406384934 title "Atraumatic splenic rupture, an underrated cause of acute abdomen" @default.
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