Saudi Journal of Gastroenterology
Home About us Instructions Submission Subscribe Advertise Contact Login    Print this page  Email this page Small font sizeDefault font sizeIncrease font size 
Users Online: 94 


 
REVIEW ARTICLE Table of Contents   
Year : 2007  |  Volume : 13  |  Issue : 4  |  Page : 163-167
Spontaneous rupture of the malarial spleen


1 Department of Surgery, Fr. Muller Medical College Hospital, Kankanady, Mangalore - 575 002 (DK.), Karnataka, India
2 Department of Medicine, Fr. Muller Medical College Hospital, Kankanady, Mangalore - 575 002 (DK.), Karnataka, India

Click here for correspondence address and email

Date of Submission18-Dec-2006
Date of Acceptance16-Mar-2007
 

   Abstract 

Spontaneous rupture of the spleen is a well-described occurrence in many diseases, being most commonly found in malaria. Exact incidence of this complication is not clear. In this article, we discuss pathology, diagnostic approach and therapeutic options in a patient with malarial splenic rupture. Ruptures of malarial spleens do heal and attempts at splenic lavage/conservative approach should be the aim in their management. Splenectomy should be reserved for those patients with severe rupture or those with continued or recurrent bleeding.

Keywords: Malaria, ruptured spleen, splenomegaly

How to cite this article:
Tauro LF, Maroli R, D'Souza CR, Hegde BR, Shetty SR, Shenoy D. Spontaneous rupture of the malarial spleen. Saudi J Gastroenterol 2007;13:163-7

How to cite this URL:
Tauro LF, Maroli R, D'Souza CR, Hegde BR, Shetty SR, Shenoy D. Spontaneous rupture of the malarial spleen. Saudi J Gastroenterol [serial online] 2007 [cited 2019 Aug 21];13:163-7. Available from: http://www.saudijgastro.com/text.asp?2007/13/4/163/36745


The spleen plays an important role in malaria, producing antibodies against the malarial parasite. The splenic involvement in malaria causing splenomegaly makes it more prone to complications such as rupture. [1],[2] Pathological or spontaneous rupture of the malarial spleen, i.e., nontraumatic rupture is a rare complication as the malarial spleen is tougher than the normal spleen. In areas where malaria is endemic, spontaneous rupture of spleen is uncommon. However, increased travel to endemic areas and resistance to antimalarial drugs have made malaria a major medical problem, which is becoming increasingly important to surgeons worldwide. [3],[4]


   Etiology Top


Spontaneous rupture of the spleen is well-described in many diseases, most commonly in malaria. [4],[5],[6] Other diseases in which spontaneous rupture of the spleen occurs, include infectious mononucleosis, splenic neoplasm and hematological malignancies. [7],[8],[9],[10],[11] Malarial parasites have been with us throughout human history. They probably originated in Africa (along with humans) and fossils of mosquitoes show that vectors for malaria have existed for at least 30 million years. Plasmodium parasites are highly specific with humans being the only vertebrate host and Anopheles mosquitoes the vectors. [12]


   Incidence Top


A total of 18 cases of malarial splenic rupture have been reported since 1960 [Table - 1]. Incidence rates of splenic rupture in naturally occurring infection ranged from 0% (0 rupture / 5870 total cases of infection) to 2% (1 rupture / 51 total cases of infection). [13],[14],[15] The only series of splenic rupture in induced infections reported an incidence of 0.4% (3 ruptures / 715 total cases of infection). [15] That only 22 cases have been reported since 1960 (including our cases) suggests under-reporting or under-diagnosis, especially for those cases of splenic rupture attributed to naturally acquired infection. [1],[2],[11],[13],[14],[15],[16],[17],[18],[19],[20],[21] Naturally acquired infections are acquired via a mosquito bite or transplacentally. [11] Induced infection spreads through blood transfusion, sharing needles, laboratory accidents and experimental or therapeutic inoculation. [11]


   Pathology and Mechanism of Malarial Splenic Rupture Top


Splenic enlargement is very common in malaria-endemic regions of the world. It is found in 50-80% of some populations. [22] When a palpable spleen is present, it is generally appreciated within 3-4 days of the onset of symptoms. If the disease remains untreated the spleen can grow considerably. This results in a greater average spleen size in a given population as the prevalence of malaria increases. [10] Plasmodium vivax has been the species most closely associated with rupture of the spleen in both naturally acquired and induced infections. [20] Among malaria-related, enlarged spleen cases reported after 1960, 12 out of 18 were due to P. vivax . (15 out of 22 including our cases). Four out of 18 were due to P. falciparum (five out of 22 including our cases) and two out of 18 were due to P. malariae [Table - 1].

Despite the often massive splenic size in chronic malaria, spontaneous rupture of the spleen occurs almost always exclusively during acute infection and usually during the primary attack. This occurrence is probably due to rapid hyperplasia, stretching of splenic parenchyma and the capsule, a high frequency of small infarctions, haemorrhage, tears, a lack of extensive connective tissue and fibrosis (as found in chronic malarial spleens), an increased risk of minor stress to the spleen ( e.g ., vomiting, rigors) and a lack of prior immunity. [20],[21]

The exact mechanism of spleen rupture is not known. However, three mechanisms have been implicated in the process. [3] The first of these mechanisms is an increase in intrasplenic tension that is due to cellular hyperplasia and engorgement. Second, the spleen may be compressed by abdominal musculature during physiological activities such as sneezing, coughing, defecating and sitting up or turning in bed. Finally, vascular occlusion due to reticuloendothelial hyperplasia may be involved which ultimately results in thrombosis and infarction. This leads to interstitial and subcapsular hemorrhage and stripping of the capsule, which further results in the distended capsule finally giving way.

Pathological findings in spontaneous rupture of the spleen include gross and microscopic changes. On gross examination, acute malarial spleen is dark red because of congestion, hyperemia and the deposition of hemozoin (a malarial pigment). The capsule is thin and friable. The chronic malarial spleen tends to be dark grey, with an increased density of connective tissue and fibrosis, resulting in a heavy, often massively enlarged organ with a firm or hard capsule. In addition, disruption of the spleen capsule along with single or multiple tears in the underlying parenchyma may be found. Tears may be small or large [23] ([Table - 2], class I-V) and may be present on any surface. Microscopic examination reveals hemozoin, parasitized and uninfected erythrocytes and a massive proliferation of macrophages throughout the capillaries, venous sinuses and pulp spaces. There is congestion and dilatation of sinuses and scattered thrombosis, with focal necrosis in capillaries and splenic pulp. [3],[4]


   Spontaneous Rupture of the Normal Spleen Top


Two cases of spontaneous rupture of the histologically normal spleen have been reported since 1958. Atkinson [24] is credited with describing the first case of spontaneous rupture of a "normal spleen" in 1874. Orloff [25] suggested four criteria, which could qualify a given case as a true case of spontaneous rupture of normal spleen. These criteria are: (1) the absence of history of trauma, (2) the absence of any disease affecting spleen directly or indirectly, (3) absence of perisplenic adhesions or scarring and (4) the presence of normal spleen seen both macroscopically and microscopically. Coleman [26],[27] postulated that abnormal mobility of spleen, inviting repeated torsions and subsequent venous congestion, could lead to spontaneous rupture of the spleen.


   Clinical Features Top


The diagnosis of splenic rupture in malaria patients is challenging and difficult because the symptoms and signs of the underlying illness confuse the clinical picture. Also, the difficulty in diagnosis is increased by the fact that the diagnosis may not be considered initially in the absence of a history of trauma. Thus, the mortality rates are high due to diagnostic difficulties, the underlying illness itself or the medication that many of these patients receive. [28] The enlarged spleen is very vulnerable and the slightest abdominal trauma or shock can be sufficient for rupture. Splenic rupture in malaria is a real pitfall for clinicians as it can happen without fever attacks and without trauma. The sudden onset of abdominal pain in a malarial patient with hypotension, tachycardia and anemia warrants an investigation for a ruptured spleen.

Abdominal pain, generalized or localized in the left upper quadrant, hypotension and tachycardia may be the only symptoms of splenic rupture in malaria. Abdominal guarding is not always present and the ruptured spleen can be missed on palpation. Pain at the tip of the left shoulder (Kehr's sign) is an evidence of diaphragmatic irritation but it occurs in less than one half of the patients. Placing the patient in a Trendelenburg position may result in the above mentioned pain due to diaphragmatic irritation. Tenderness in the left upper quadrant is a frequent physical sign and a mass or a percussible area of fixed dullness in this region (Ballance's sign) has been described but is rarely detected. [29] Signs of hypovolaemia, abdominal distension and absence of bowel sounds will be detected. The patient may later develop hypovolemic shock.


   Investigations Top


In the first few hours, laboratory tests are unhelpful as hemoglobin (Hb) levels have not yet been adjusted by hemodilution. Abdominal ultrasound or abdominal puncture can confirm the diagnosis of this complication but in field conditions, only an explorative laparotomy can reveal the true diagnosis. A blood sample is required for baseline Hb, packed cell volume (PCV) estimation and for cross-matching of blood. A chest X-ray may reveal elevation of the left hemidiaphragm and an abdominal X-ray may show increased density in the left upper quadrant, obliteration of the splenic outline and psoas shadow, indentation of the left side of the stomach and air bubbles or free fluid between gas field intestinal coils. However a completely normal abdominal X-ray does not exclude a ruptured spleen.

Abdominal ultrasound will detect splenic rupture, subcapsular hematoma, perisplenic collection and free fluid (blood) in the peritoneal cavity. [28] In most cases no further investigation is needed. The diagnosis of a ruptured spleen is essentially a clinical one based on symptoms, signs and observation of the pulse and blood pressure charts. As soon as the diagnosis is made, urgent laparotomy is needed to halt bleeding. Computerized tomography (CT) scan of the abdomen will detect the smallest subcapsular hematoma of the spleen before the rupture occurs. Hence, the CT scan is useful in diagnosis and monitoring a patient with conservative management for splenic rupture.

Peritoneal lavage or four-quadrant aspiration may be useful and reveal the presence of blood. Great care is taken over the technique of peritoneal lavage. The patient's bladder is emptied with a Foley's catheter, the skin below the umbilicus is infiltrated with a local anaesthetic and a small midline incision made. The linea alba is incised, the cut edges pulled up with forceps and a small opening made in the peritoneum through which a peritoneal dialysis catheter is inserted. When hemostasis is meticulous, this technique allows a confident diagnosis of intraperitoneal bleeding to be made if the lavage fluid returns blood-stained. Provided a slight head-down tilt is used, it is very unlikely that false negatives will be obtained with peritoneal lavage. [28]

Radioisotope imaging of spleen has occasionally been found to be useful in a patient with ruptured spleen. The diagnosis may be established angiographically by visualization of (1) disruption of the parenchyma, (2) radio-opacity in the peritoneal cavity and (3) early filling of the splenic vein. [29]


   Treatment Top


Apart from appropriate antimalarial therapy, splenectomy is accepted as the treatment of choice in cases of spontaneous rupture of the spleen. [2],[4] Of the 22 patients described since 1960 (including our study), 16 patients underwent surgical procedures, all of which were splenectomy [Table - 1]. For patients in malaria-endemic areas and others who travel frequently to these areas, splenic preservation after rupture is critical and a conservative strategy should be attempted. [4],[21] In regions in which malaria is not endemic, increased preoperative and postoperative risk of splenectomy, have led to attempted nonoperative management of splenic rupture (in cases of penetrating and blunt trauma). [30] In addition to the significant morbidity and mortality of splenectomy itself, reasons to avoid splenectomy in areas where malaria is not endemic, include increased risk of fatal malaria, the possibility of remission, poor postoperative wound healing and the risk of cerebral malaria. Moreover, as fragmentation of the spleen is unusual when operative therapy is adopted, a large part of the spleen can be surgically repaired (splenorrhaphy). [20],[21] Clezy and Richens [1] described nonoperative management of a spontaneously ruptured malarial spleen.

Non-operative Management

Nonoperative management of splenic rupture consists of observation for 7-14 days in the hospital, strict bed-rest and administration of fluids and blood as needed. [1],[2],[4],[31] Hb and PCV should be monitored daily. Repeated ultrasonography or CT scan is done to assess the healing of the ruptured spleen which is usually complete in 2-3 weeks. [32] Splenectomy should be reserved for those patients with severe rupture or those with continued or recurrent bleeding. [20]

Splenorrhaphy

The techniques used to preserve splenic tissue and function are adopted based on the extent of damage. Small lacerations can be managed by compression and the application of a hemostatic agent such as oxidized cellulose or micronized collagen. Hemostasis associated with significant disruption of the splenic capsule and parenchyma can generally be managed with absorbable sutures that traverse the capsule and enter the parenchyma. In this circumstance, the horizontal mattress suture is advantageous because it minimizes cutting through tissues. In case of more profound bleeding, the splenic artery can be ligated at the hilus, following which the transcapsular suture is inserted and tied. If one pole of the spleen is damaged, this area should be resected and the edges approximated with a series of mattress sutures. The omentum may be used to fill large defects or to suture over the injury site to provide tamponade.

Complications of splenectomy

Early postoperative bleeding, subphrenic abscess, left lower lobe atelectasis, deep venous thrombosis and postsplenectomy sepsis are few of the recognized complications of splenectomy. Postsplenectomy sepsis and fulminent sepsis due to pneumococci and H. influenzae have been well-established as complications of splenectomy. All patients subjected to splenectomy should be treated with pneumovax and younger patients should receive long-term antibiotic prophylaxis against H. influenzae sepsis until they reach adulthood. The authors have come across four cases of spontaneous malarial splenic rupture, out of which, three were due to P. vivax and one due to P. falciparum . Two cases were treated conservatively and splenectomy was performed in other two cases. All patients survived.


   Conclusion Top


Spontaneous splenic rupture is a fatal complication of malaria, which requires a critical decision in its management. Most malarial splenic ruptures do heal, hence, attempts at splenic salvage should be the aim in their management.

 
   References Top

1.Clezy JK, Richens JE. Non-operative management of spontaneously ruptured malarial spleen. Br J Surg 1985;72:990.  Back to cited text no. 1    
2.Mokashi AJ, Shirahatti RG, Prabhu SK, Vgholkar KR. Pathological Rupture of Malarial spleen. J Postgrad Med 1992;38:141-2.  Back to cited text no. 2    
3.Patel MI. Spontaneous Rupture of a malarial spleen. Med J Aust 1993;159:836-7.  Back to cited text no. 3    
4.Yagmur Y, Kara IH, Aldemir M, Buyukbayram H, Tacyildiz IH, Keles C. Spontaneous rupture of malarial spleen: Two case reports and review of literature. Crit Care 2000;4:309-13.  Back to cited text no. 4    
5.Bucinto R, Kald A, Borch K. Spontaneous rupture of spleen. Eur J Surg 1992;158:129-30.  Back to cited text no. 5    
6.Schwartz SI. Spleen. In : Principle of surgery, 5 th ed. Schwartz SI, Shires GT, Spencer FC, Storer EH, editors. Mc Graw - Hill: New York; 1989. p. 1445-57.  Back to cited text no. 6    
7.Baralkiewicz G, Mijal J, Karan J, Rybski Z, Juszczyk J. Spontaneous splenic rupture as a complication of infections mononucleosis. Przegl Epidemiol 1996;50:435-41.  Back to cited text no. 7    
8.Alberty R. Surgical implications of infectious mononucleosis. Am J Surg 1981;141:559-61.  Back to cited text no. 8    
9.Pettersen JT, Modalsli O, Solheim K, Buanes T. Splenic neoplasms. Tidsskr Nor Laegeforen 1993;113:1468-9.  Back to cited text no. 9    
10.Russel PF, West LS, Manwell RD, Macdonald G, editors. Practical malariology. 2 nd ed. Oxford University Press: London; 1963. p. 371-485.  Back to cited text no. 10    
11.Bearn JG. Spontaneous rupture of malarial spleen. A case report and some anatomical and pathological considerations. Trans R Soc Trop Med Hyg 1961;55:242-5.  Back to cited text no. 11    
12.World Health Organization. The biology of malarial parasites: Report of a WHO scientific group. WHO Technical Report Series: Geneva; 1987. No.743: 179-99.  Back to cited text no. 12    
13.Martelo OJ, Smoller M, Saladin TA. Malaria in American soldiers. Arch Intern Med 1969;123:383-7.  Back to cited text no. 13    
14.Khan MY, Zinneman HH, Hall WH. Vietnam malaria: Clinical experience with 50 patients. Minn Med 1970;53:331-4.  Back to cited text no. 14    
15.Howard WA, Krotoski WA, Slonim MS, Contacos PG. Spontaneous splenic rupture in vivax malaria: Case report. Mil Med 1973;138:32-5.  Back to cited text no. 15    
16.Davis R. Spontaneous rupture of the pathological spleen in malaria. S Afr Med J 1973;47:1801-3.  Back to cited text no. 16    
17.Walzer PD, Gibson JJ, Schwltz MG. Malaria fatalities in the United States. Am J Trop Med Hyg 1974;23:328-33.  Back to cited text no. 17    
18.Touze JE, Garnotel E, Mannet G, Ducorerau JP, Beaute D, Zimmerman JC, et al . Spontaneous spleen rupture in malaria. Trans R Soc Trop Med Hyg 1989;83:161.  Back to cited text no. 18    
19.Falk S, Protz H, Kobrich U, Stutte HJ. Spontaneous splenic rupture in acute malaria tropica. Deutsch Med Wochenschr 1992;117:854-7.  Back to cited text no. 19    
20.Zingman BS, Viner BL. Splenic complication in malaria: Case report and review. Clin Infect Dis 1993;16:223-32.  Back to cited text no. 20    
21.Baidas WH, Al-Zamil A, Mathew CV. Spontaneous rupture of a malarial spleen. Annals Saudi Med 1999;19:139-40.  Back to cited text no. 21    
22.Strickland GT. Malaria. In : Hunter's tropical medicine. 7 th ed. Strickland GT, editor. WB Saunders: Philadelphia; 1991. p. 586-617.  Back to cited text no. 22    
23.Cogbill TH, Moore EE, Jurkovich GJ, Morris JA, Mucha P Jr, Shackford SR, et al . Non-operative management of blunt splenic trauma: A multicenter experience. J Trauma 1989;29:1312-7.  Back to cited text no. 23    
24.Atkinson E. Death from idiopathic rupture of spleen. BMJ 1874;2:403-4.  Back to cited text no. 24    
25.Orloff MJ, Peskin GW. Spontaneous rupture of the normal spleen, a surgical enigma. Surg Gynaecol Obstet 1958;106:1-11.  Back to cited text no. 25    
26.Coleman AH. Spontaneous rupture of the normal spleen. Br J Surg 1939;27:173.  Back to cited text no. 26    
27.Kumar S, Gupta A, Shrivastava UK, Mathur SB. Spontaneous rupture of normal spleen: An enigma recalled. Br J Clin Pract 1992;46:67-8.  Back to cited text no. 27    
28.Cochrane JP. The spleen. Ruptured spleen. J Appl Med 1981;7:353-6.  Back to cited text no. 28    
29.Schwartz SI. The spleen. In : Maingot's abdominal operation, 10 th ed. Vol II, Zinner MJ, Schwartz SI, Ellis H, editors. International ed. Appleton and Lange: 1997. p. 2031-61.  Back to cited text no. 29    
30.Shaw JH, Print CG. Postsplenectomy sepsis. Br J Surg 1989;76:1074-81.  Back to cited text no. 30    
31.Hamilton DR, Douglas P. Ruptured spleen in acute malarious area: With emphasis on conservative management in both adults and children. Aust NZ J Surg 1982;52:310-3.  Back to cited text no. 31    
32.Ruptured spleen in the adult: An account of 205 cases with particular reference to non-operative management. Papua New Guinea Splenic Injury Study Group. Aust NZJ Surg 1989;57:549-53.  Back to cited text no. 32    

Top
Correspondence Address:
Leo F Tauro
Department of General Surgery, Fr. Muller Medical College Hospital, Kankanady, Mangalore - 575 002 (D.K.)
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.36745

Rights and Permissions



 
 
    Tables

  [Table - 1], [Table - 2]

This article has been cited by
1 Spontaneous rupture of falciparum malarial spleen presenting as hemoperitoneum, hemothorax, and hemoarthrosis
Ahmed E. Mahmoud
American Journal of Case Reports. 2013; 14: 405
[Pubmed] | [DOI]
2 Spontaneous splenic rupture presenting as haemoperitoneum: Coinfection of Plasmodium vivax and Plasmodium falciparum
Agarwal, A.A. and Sonkar, A. and Kushwaha, J. and Gaurav, K.
BMJ Case Reports. 2013; (008851)
[Pubmed]
3 Multi-detector computed tomography of spleen
Botchu, R. and Rao, B. and Tyagi, R. and Griffin, Y.
Hong Kong Journal of Radiology. 2011; 14(4): 249-261
[Pubmed]
4 Spontaneous rupture of malarial spleen presenting as hemoperitoneum: A case report
Gupta, N. and Lal, P. and Vindal, A. and Hadke, N.S. and Khurana, N.
Journal of Vector Borne Diseases. 2010; 47(2): 119-120
[Pubmed]
5 Non-traumatic splenic rupture: Report of seven cases and review of the literature
Gedik E, Girgin S, Aldemir M, et al.
WORLD JOURNAL OF GASTROENTEROLOGY. 2008; 14(43): 6711-6716
[Pubmed]



 

Top
 
  Search
 
  
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Etiology
    Incidence
    Pathology and Me...
    Spontaneous Rupt...
    Clinical Features
    Investigations
    Treatment
    Conclusion
    References
    Article Tables

 Article Access Statistics
    Viewed5366    
    Printed141    
    Emailed1    
    PDF Downloaded515    
    Comments [Add]    
    Cited by others 5    

Recommend this journal