Case Presentation: 44-year-old male with past medical history of diabetes mellites, hypertension, pancreatitis and hypertriglyceridemia presented to the ED with acute abdominal pain and vomiting. Physical examination was unremarkable other than epigastric tenderness and elevated BMI of 33. Chemistry revealed glucose: 259 mg/dL, bicarbonate: 20 mmol/L, anion gap 19, lipase 1170 U/L, WBC count 15.6K/cc, Hb 13.3 g/dL, Cr 4.9, urine ketones 80 mg/dL, triglycerides >4425 mg/dL. CT of abdomen without contrast showed acute moderate to severe interstitial edematous pancreatitis with focal necrosis with fluid collection with new onset splenic vein thrombosis. Patient was started on DKA management. On day two, he had fever of 102.5 F, with new acute shoulder pain. BP was 97/64 mmHg, HR 114/min. He was given a normal saline bolus, started on vancomycin and piperacillin-tazobactam, and low-dose norepinephrine, but his BP remain 89/60 mmHg, and Cr increased to 6.5. Repeat CT revealed splenic rupture with large amount of blood in left upper quadrant surrounding an indistinct spleen, large hematoma adjacent to liver, and moderate amount of diffuse hemoperitoneum. Hb had decreased to 4.6 gm/dl. Anticoagulation was discontinued, and he received four-factor PCC, and 3U of PRBC. Patient underwent an emergency splenectomy; in addition, CT angiography was obtained for distal pancreatic necrosectomy and suture ligation of the splenic artery for concerning of rebleeding from splenic hilum, possible splenic artery aneurysm or other vascular anomalies. Post-surgery, repeat Hb was improved to 9gm/dl. He was started on an oral diet, and later discharged to home.
Discussion: Hypertriglyceridemia is one of the common causes for acute pancreatitis. Splenic vein thrombosis often occurs due to the inflammatory process of the pancreatitis causing damage to the vein and induce clot formation leading to increased pressure within the spleen. We describe a rare case who developed splenic rupture combined with acute hemorrhagic shock during course of treatment for hypertriglyceridemia-induced acute pancreatitis with splenic vein thrombosis.
Conclusions: Atraumatic splenic rupture is rare and serious complication of pancreatitis, especially combined with splenic vein thrombosis. Hemodynamic instability should raise concern for intraperitoneal vascular crisis. The pathophysiology is closely linked to splenic vein obstruction, pseudocysts, or necrosis in the tail of the pancreas, intravascular volume depletion, a procoagulant microenvironment, and other elements of initial distributive shock.