Atraumatic splenic rupture in a patient treated with apixaban: A case report

INTRODUCTION: Splenic rupture is often seen in the context of significant trauma. Atraumatic ruptures are described in the context of malignancy, inflammation or infection directly affecting the spleen. Splenic ruptures occurring in patients taking apixaban, a factor Xa inhibitor, are challenging due to the scarcity of a direct reversal agent. PRESENTATION OF CASE: A 66 year old male presented with syncope and back pain and was found to be haemodynamically unstable and tender in the left upper quadrant. There was no preceding trauma. He has a background of extensive major arterial reconstruction and was taking apixaban for atrial fibrillation. A diagnosis of splenic rupture was confirmed on cross sectional imaging. A laparotomy and splenectomy was necessitated as salvage therapy following splenic artery embolisation. He recovered well and was discharged home 6 days after laparotomy. CONCLUSION: Definitive intervention is required for the management of splenic ruptures. A high level of clinical suspicion should be maintained in patients taking direct oral anticoagulants presenting with haemodynamic instability. Open splenectomy remains the most definitive option for treatment of atraumatic rupture in anticoagulated patients.