AB174. 104. The shattered spleen—an unexpected complication of the ulcerated foot

Background: A 50-year-old male smoker was admitted with a 5-week history of unresolving right foot cellulitis, despite antibiotic therapy, with a newly developing ulcer at the base of the 4th metatarsal. He was commenced on therapeutic low molecular weight heparin (LMWH) and iloprost. He remained vitally stable and comfortable. A computed tomography (CT) angiogram of the lower limbs incidentally identified a significant splenic laceration. With no history of trauma or significant known risk factors, a CT abdomen & pelvis was performed 2 hours later, which revealed a significant haemoperitoneum with significant extravasation from a now completely ruptured spleen, developing haemorrhagic shock. The patient was immediately transferred to theatre where he underwent an emergency laparotomy and splenectomy for a shattered spleen, whilst receiving extensive resuscitation with blood products. Once stable, he was transferred to intensive care unit (ICU) (7 days) and then discharged on day 10 post operatively, without complication.

Methods: Retrospective case report. Conducted using patients’ chart, imaging reports from national integrated medical imaging service (NIMIS), and theatre notes.

Results: A CT angiogram of the lower limbs incidentally identified a significant splenic laceration. With no history of trauma or significant known risk factors, a CT abdomen & pelvis was performed 2 hours later, which revealed a significant haemoperitoneum with significant extravasation from a now completely ruptured spleen, developing haemorrhagic shock. The patient was immediately transferred to theatre where he underwent extensive resuscitation with blood products, an emergency laparotomy and splenectomy for a shattered spleen. Once stable, he was transferred to ICU (7 days) and then discharged on day 10 post operatively, without complication.

Conclusions: This case highlights a very fortunate incidental finding on imaging, in an unpredictable splenic rupture. With no identifiable risk factors or cause for such a rupture, this case identifies the potential risk of LMWH, and the possible attenuating effect of a prostacyclin such as Iloprost in exacerbating the risk. We hypothesize that the combination of LMWH & Iloprost to be the cause of this spontaneous splenic rupture.

Keywords: Splenectomy; anticoagulation; foot ulcer; radiology; laparotomy