A 74-year-old woman is brought to the emergency department after acute onset of abdominal pain followed by syncope. The patient was in an exercise class when she suddenly had pain in the left side of her abdomen, quickly followed by loss of consciousness for 30 seconds. She has persistent nausea, dizziness, and diffuse abdominal pain. The patient had no seizure-like activity, chest pain, palpitations, rectal bleeding, or incontinence. There was no trauma. She was diagnosed with chronic lymphocytic leukemia 5 years ago. Other medical conditions include recurrent infections, atrial fibrillation, diverticulosis, and hypertension. Medications include apixaban, metoprolol, and amlodipine, and she has been taking them as prescribed. The patient drinks 4 glasses of wine daily. She does not use tobacco. On examination, the patient is lethargic, pale, and in moderate distress due to abdominal pain. Temperature is 37.3 C (99.1 F), blood pressure is 80/54 mm Hg, pulse is 120/min, and respirations are 14/min. The abdomen is diffusely tender. Bowel sounds are decreased. Laboratory results are as follows: Which of the following is the most likely diagnosis?

Question

A 74-year-old woman is brought to the emergency department after acute onset of abdominal pain followed by syncope.  The patient was in an exercise class when she suddenly had pain in the left side of her abdomen, quickly followed by loss of consciousness for 30 seconds.  She has persistent nausea, dizziness, and diffuse abdominal pain.  The patient had no seizure-like activity, chest pain, palpitations, rectal bleeding, or incontinence.  There was no trauma.  She was diagnosed with chronic lymphocytic leukemia 5 years ago.  Other medical conditions include recurrent infections, atrial fibrillation, diverticulosis, and hypertension.  Medications include apixaban, metoprolol, and amlodipine, and she has been taking them as prescribed.  The patient drinks 4 glasses of wine daily.  She does not use tobacco.  On examination, the patient is lethargic, pale, and in moderate distress due to abdominal pain.  Temperature is 37.3 C (99.1 F), blood pressure is 80/54 mm Hg, pulse is 120/min, and respirations are 14/min.  The abdomen is diffusely tender.  Bowel sounds are decreased.  Laboratory results are as follows:  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d90b_0e07_bc81_757d6c63592a_MD0003_00 This patient with acute-onset abdominal pain, shock, and acute anemia likely has splenic rupture, an uncommon but life-threatening complication of chronic lymphocytic leukemia (CLL). Most cases of rupture are associated with blunt abdominal trauma; however, atraumatic rupture can also occur. Common predisposing factors for atraumatic rupture include hematologic malignancy (eg, leukemia, lymphoma), infection (eg, Epstein-Barr virus mononucleosis), and inflammatory disease (eg, systemic lupus erythematosus). These conditions can lead to splenomegaly, derangement of the splenic architecture, and/or thinning of the splenic capsule, increasing the risk of rupture. In the setting of concomitant anticoagulation (eg, apixaban for atrial fibrillation) the chances of rupture are greatly increased. Examination may reveal hemodynamic instability, diffuse abdominal pain, and signs of peritonitis (eg, rebound, guarding). On occasion, pain may be referred from the diaphragm and phrenic nerve to the left shoulder (Kehr sign). Focused abdominal ultrasound or CT scan demonstrates free intraperitoneal fluid. Splenectomy is the management of choice in hemodynamically unstable patients, although catheter-based angioembolization may be attempted in stable patients. CT scan (Choice A) Bowel perforation can present with diffuse abdominal pain, signs of peritonitis, and shock; however, it would not explain an acute drop in hemoglobin. (Choice B) Acute colonic ischemia presents with abdominal pain, but the pain is typically sudden, cramping, and localized. Tenesmus and rectal bleeding or bloody diarrhea may also follow. (Choice C) Mesenteric artery occlusion causes abdominal pain, but examination is usually unrevealing with pain being out of proportion to findings. Occlusion can occur either from ruptured plaque with in situ thrombus or from a thromboembolic event (eg, due to atrial fibrillation). The diagnosis is less likely in this patient who is taking apixaban as prescribed (coagulation parameters [eg, PT/INR, PTT] are not reliable indicators of direct oral anticoagulant activity). (Choice D) Necrotizing pancreatitis, similar to other severe inflammatory states, can predispose to splenic rupture, but patients usually first have signs and symptoms of acute pancreatitis such as fever, tachypnea, and severe epigastric pain radiating to the back. Syncope and acute anemia are uncommon. (Choice E) Septic shock can present with hemodynamic instability and leukocytosis, but a neutrophil-predominant leukocytosis is expected. This patient's lymphocyte-predominant leukocytosis is consistent with underlying CLL. Educational objective: Atraumatic splenic rupture is an uncommon but life-threatening complication of hematologic malignancy, infection, and systemic inflammatory disease, and anticoagulation increases the risk. Patients develop acute abdominal pain, shock, and anemia. Peritonitis and left shoulder pain may also be present. References: Diagnosis and treatment of atraumatic splenic rupture: experience of 8 cases. (http://www.ncbi.nlm.nih.gov/pubmed/30809256) Atraumatic splenic rupture associated with apixaban. (http://www.ncbi.nlm.nih.gov/pubmed/30815265)

A 74-Year-Old Woman Is Brought to the Emergency Department After