A case of spontaneous splenic rupture causing hemorrhagic shock in a 74-year-old on Apixaban

Abstract

Spontaneous splenic rupture is a rare, life-threatening cause of atraumatic intra-abdominal hemorrhage and may occur in patients receiving anticoagulation. We present a 74-year-old woman with atrial fibrillation treated with apixaban who presented with one day of worsening abdominal pain and near-syncope without preceding trauma. She was hypotensive on arrival, with hemoglobin of 5.8 g/dl, elevated lactate, and acute kidney injury. Computed tomography (CT) of the abdomen and pelvis demonstrated a lower-pole splenic laceration with active contrast extravasation, subcapsular hematoma, and hemoperitoneum. She underwent immediate resuscitation with intravenous fluids, packed red blood cells, and prothrombin complex concentrate for anticoagulant reversal, followed by emergent exploratory laparotomy. Operative findings confirmed hemoperitoneum and an actively bleeding spleen with capsular avulsion; splenectomy was performed. Her postoperative course included intensive care monitoring, additional transfusion support, temporary pharmacologic thromboprophylaxis that was discontinued because of incisional bleeding, and post-splenectomy vaccination. She was discharged on postoperative day 7 without anticoagulation pending cardiology follow-up and remained clinically well at subsequent postoperative visits. This case highlights spontaneous splenic rupture as an important diagnostic consideration in anticoagulated patients presenting with unexplained abdominal pain, anemia, or hemodynamic instability despite no history of trauma. Prompt imaging, anticoagulant reversal, resuscitation, and definitive operative management are critical to survival, while post-hemorrhage anticoagulation decisions require individualized multidisciplinary assessment.