Spontaneous splenic rupture associated with apixaban: a case report

Abstract

BackgroundSpontaneous splenic rupture associated with anticoagulant use is a rare but potentially lethal disorder. Lack of prompt recognition can be associated with poor patient outcomes. The use of novel oral anticoagulants is becoming more common and thus consideration of this disorder while evaluating a patient who presents with abdominal pain while using these agents is extremely important. This is the first reported case of spontaneous splenic rupture associated with apixaban.Case presentationWe describe the clinical case of an 83-year-old white man who complained of sudden severe abdominal pain 5 days into a hospital stay for acute-on-chronic congestive heart failure and exacerbation of chronic obstructive pulmonary disease. Neither he nor his wife reported any significant trauma for the past 6 months prior to his admission. His medical history included chronic atrial fibrillation treated with medications including apixaban 2.5 mg twice daily. An urgent abdominal computed tomography scan demonstrated a large splenic hematoma and evidence of intraperitoneal bleeding from which he rapidly declined, developing hypovolemic shock. An emergency splenic arteriogram displayed a patent splenic artery and an embolization was successful in stabilizing him. Due to evidence of recurrent bleeding, an exploratory laparotomy and splenectomy was subsequently performed the following day.ConclusionsThe diagnosis of spontaneous splenic rupture is important to consider in a patient using apixaban who presents with abdominal pain and associated signs of hypotension and anemia. For hemodynamically unstable patients, prompt treatment to stop significant bleeding through splenic artery embolization or splenectomy is warranted and may be lifesaving.

Spontaneous splenic rupture due to rivaroxaban

“…Previously, there have been reports of spontaneous splenic ruptures with apixaban9 and dabigatran 10. In our case, the interaction between amiodarone, a P-glycoprotein inhibitor and rivaroxaban potentially could have increased the activity of rivaroxaban,11 resulting in major bleeding.…”

Spontaneous splenic rupture secondary to dabigatran: the last in a series of unfortunate events

“…However, there are a few case reports of spontaneous ruptures secondary to anticoagulation alone. 3,4 In one systematic review, it was estimated that only 9.1% of spontaneous ruptures were drug or treatment related; 5 however, more recent papers have estimated the incidence to be higher. Clues to the diagnosis include left-sided abdominal pain that may be referred to the shoulder, falling haemoglobin levels and features of shock.…”

Splenic rupture following synchronised direct current cardioversion

“…Our patient was taking the direct oral anticoagulant medication apixaban for stroke prophylaxis in the setting of underlying AFL. There is one known case of spontaneous haemorrhage resulting from cough in a patient receiving apixaban 20. Other anticoagulation medications including thrombolytic agents, heparin and low-molecular weight heparin products, and warfarin have also been implicated as factors leading to spontaneous splenic rupture 13 21 22.…”