On physical examination, a subtle swelling of the left upper quadrant was noted. The abdomen was soft but markedly tender to palpation diffusely with mild guarding. Laboratory studies revealed an initial hematocrit of 42.8%, and urine toxicology was positive for cocaine. Computed tomography (CT) scan of the abdomen and pelvis with oral and intravenous contrast showed learn more no evidence of free peritoneal air or injury to any solid organs or bones including the ribs, but did reveal fluid around the spleen, in the left paracolic gutter, and layering in the pelvis (Figures 1, 2 and 3). There was no evidence of active contrast extravasation, no vascular

blushes or aneurysms, no findings of portal hypertension, and no suspicion for malignancy. These radiographic findings pointed to a splenic source for hemoperitoneum.

Six hours after presenting to the ED, the patient’s hematocrit had dropped to 36.6%, and repeat CT scan revealed a focal collection of fluid surrounding the spleen. Given that the patient remained hemodynamically stable, he was admitted for non-operative management in the surgical intensive care unit, where he had serial abdominal examinations and blood count monitoring. Figure 1 Axial, contrast-enhanced CT image demonstrates moderate SIS3 clinical trial hemoperitoneum in left upper quadrant centered around the spleen. Figure 2 Sagittal, contrast-enhanced CT Selleck Venetoclax image demonstrates perisplenic hematoma. Figure 3 Axial, contrast-enhanced CT image of the pelvis demonstrates large hemoperitoneum. The patient did not require transfusion as his hematocrit remained

stable between 36% and 38% throughout his hospital course. During that time, infectious etiologies including Epstein-Barr virus and cytomegalovirus were ruled out as 4-Hydroxytamoxifen clinical trial possible causes. A human immunodeficiency virus test performed two weeks prior to this admission was negative. Additionally, hematologic malignancy was excluded with a peripheral blood smear. The patient’s symptoms significantly improved and he was discharged on hospital day four. On follow-up ten days after initial presentation, the patient’s symptoms had resolved and his vital signs were stable. An abdominal ultrasound revealed a subcapsular splenic hematoma at the tip of the spleen tracking anteriorly with interim resolution of free fluid in the pelvis, confirming a splenic etiology for hemoperitoneum (Figure 4). Although the patient’s CT scan did not show a blush suggestive of a pseudoaneurysm, the diagnosis of a splenic artery pseudoaneurysm could have been investigated further with a splenic angiogram. Figure 4 2D gray scale ultrasound image demonstrates small degree of subcapsular splenic hematoma. Conclusions Splenic rupture in the absence of trauma is exceedingly rare.