Hrev_master [page 26] [Emergency Care Journal 2015; 11:5257] Imaging sketch of bedside ultrasonography to improve the diagnosis of rupture of splenic artery aneurysm Bahjat Barakat,1 Raffaele Pezzilli2 1Department of Emergency, S. Orsola- Malpighi University Hospital, Bologna; 2Department of Digestive System, S. Orsola-Malpighi University Hospital, Bologna, Italy Splenic artery aneurysm (SAA) is a rare cause of upper abdominal pain. In autopsy studies, its incidence ranges from 0.01 to 0.2% and increases to 10% in older patients;1 also, the incidence is higher in female gender as compared to male gender with a ratio of 4:1.2 The diagnosis of this disease is clinically diffi- cult without imaging.3-6 Due to rarity of this disease, we considered noteworthy to report the imaging, which lies to a diagnosis of SAA in a 58-year-old woman who was admitted to Emergency Room for the rapid onset of epi- gastric pain, not associated with other symp- toms. She was previously cholecystectomized for gallstones and she did not take any medica- tion. The clinical parameters were within the normal limits: arterial blood pressure was 110/60 mmHg, blood oxygen saturation levels (99%), cardiac rate 60 b.p.m., and body temper- ature of 36°C. The electrocardiogram was nor- mal as well as the cardiac and pulmonary phys- ical examination. There was a mild tenderness of the abdomen without signs of peritoneal irritation or pulsatile mass. There was pallor of the skin. The biochemistry revealed an increase of white cell count (13.990 mmc), a reduced levels of Hb (10.9 g/dL) and hemat- ocrit (32.8%). Liver and renal parameters were within the normal limits as well as the coagu- lation. Both the chest and the abdomen x-rays were normal. The abdominal ultrasound showed no alterations of the liver, biliary tree, kidneys, pancreas (head and body), whereas there was the presence of a small anechoic area near to the tail of the pancreas (Figure 1); in addition, hypoechoic spots of the spleen and a moderate abdominal fluid collection were identified (Figure 2). An ultrasound-color Doppler and pulse-Doppler of the abdominal vessels were carried out showing an aneurys- matic dilation of the splenic artery (Figure 3), and a turbulent flow within the splenic artery aneurysm (Figure 4). The patient was rehy- drated with fluids and a computed tomography was carried out. The contrast-enhanced com- puted tomography showed multiple infarctions of the spleen and bloody abdominal fluid col- lection and an aneurysm of 2 cm of diameter of the SAA (Figures 5 and 6). The patient became critically in the subsequent 2 hours after admission and she underwent laparotomy. At the surgical exploration, blood was found in both the peritoneal cavity and in lesser sac as well as a rupture of the splenic artery was iden- tified. Thus, a ligation of the proximal portion of the artery together with resection of the aneurysm and spleen was carried out. The pathological examination of the resected spec- imen showed a perforated aneurysm of the splenic artery and multiple small splenic infarction areas. Splenic artery aneurysm is a rare and poten- tially life-treating disease7 and its diagnosis should be kept in mind in all those patients having a sudden onset pain in the upper abdomen with of without arterial hypotension. The risk factors of SAA include portal hyper- tension, congenital abnormalities of the ves- sels, vascular and connective vascular disor- ders, vascular trauma, or degenerative arterial diseases;8 it has been also found in pregnant women and in this latter case the maternal and fetal mortality rates are as high as 70-90%, respectively.9-11 However, in our case none of these factors were clinically apparent. Emergency surgical management may improve survival of these kinds of patients.5 An alterna- tive approach to SAA is endovascular treatment that should be preferred for those patients Emergency Care Journal 2015; volume 11:5257 Correspondence: Raffaele Pezzilli, Department of Digestive System, Sant’Orsola-Malpighi Hospital, via Massarenti 9, 40138 Bologna, Italy. Tel: +39.051.636.4148 - Fax: +39.051.636.4148. E-mail: raffaele.pezzilli@aosp.bo.it Key words: Splenic aneurysm; Ultrasonography; Ultrasound-color Doppler; Ultrasound pulse- Doppler; Computer tomography. Conflict of interest: the authors declare no poten- tial conflict of interest. Received for publication: 27 April 2015. Accepted for publication: 20 May 2015. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright B. Barakat and R. Pezzilli, 2015 Licensee PAGEPress, Italy Emergency Care Journal 2015; 11:5257 doi:10.4081/ecj.2015.5257 Figure 1. Ultrasonography: small anechoic area near to the tail of the pancreas compatible with aneurysm of the splenic artery (arrow). Figure 2. Ultrasonography: hypoechoic spots of the spleen and a moderate abdominal fluid collection. Non co mmerc ial us e o nly [Emergency Care Journal 2015; 11:5257] [page 27] unfit for surgery or those who may be treated in elective settings.5,9 Nevertheless, a correct diagnosis, especially using bedside ultrasonog- raphy, significantly improves the correct man- agement of patients having SAA in Emergency Room. References 1. Reardon PR, Otah E, Craig ES, et al. Laparoscopic resection of splenic artery aneurysms. Surg Endosc 2005;19:488-93. 2. Dave SP, Reis ED, Hossain A, et al. Splenic artery aneurysm in the 1990s. Ann Vasc Surg 2000;14:223-9. 3. Betal D, Khangura JS, Swan PJ, Mehmet V. Spontaneous ruptured splenic artery aneurysm: a case report. Cases J 2009;2: 7150. 4. Sarikaya S, Ekci B, Aktas C, et al. A rare clinic presentation of abdominal pain: rup- ture of splenic artery aneurysm: a case report. Cases J 2009;2:148. 5. Abdulrahman A, Shabkah A, Hassanain M, Aljiffry M. Ruptured spontaneous splenic artery aneurysm: a case report and review of the literature. Int J Surg Case Rep 2014;5:754-7. 6. Deshpande AA, Kulkarni VM, Rege S, et al. Ruptured true aneurysm of the splenic artery: an unusual cause of haemoperi- toneum. J Postgrad Med 2000;46:191-2. 7. Mattick A, Gawthrope I. Splenic artery aneurysm rupture: case report of this uncommon presentation. BMJ Case Rep 2009;2009:bcr10.2008.1148. 8. Selo-Ojeme DO, Welch CC. Review: spon- taneous rupture of splenic artery aneurysm in pregnancy. Eur J Obstet Gynecol Reprod Biol 2003;109:124-7. 9. Carey K, Northcutt A, Bhullar I. Successful management of delayed splenic rupture with angioembolization. Am Surg 2014;80: e265-7. 10. Khurana J, Spinello IM. Splenic artery aneurysm rupture: a rare but fatal cause for peripartum collapse. J Intensive Care Med 2013;28:131-3. 11. Sadat U, Dar O, Walsh S, Varty K. Splenic artery aneurysms in pregnancy. A system- atic review. Int J Surg 2008;6:261-5. Images in emergency Figure 3. Ultrasound-color Doppler showing an aneurysmatic dilation of the splenic artery. Figure 4. Ultrasound pulse-Doppler of the abdominal vessels showing a turbulent flow within the splenic artery aneurysm. Figure 5. Contrast-enhanced computed tomography showing multiple infarctions of the spleen and bloody abdominal fluid collection. Figure 6. Contrast-enhanced computed tomography showing an aneurysm of 2 cm of diameter of the splenic artery aneurism (red circle). Non co mmerc ial us e o nly