[Spontaneous splenic rupture. Case report and literature review]. / Ruptura esplénica espontánea. Reporte de caso y revisión de la literatura.

Background: Spontaneous splenic rupture is often life threatening due to delay in diagnosis and treatment. Abdominal pain, Kehr's sign, nausea, bloating, altered consciousness, and intestinal obstruction may be present. In larger splenic lesions, signs of peritonitis and hypovolemic shock are present. Contrast-enhanced computed tomography is the election study. Diagnosis is confirmed by negative viral serology and normal spleen on gross and histopathologic inspection. The most frequent treatment in splenectomy. Clinic case: A 30-year-old male with no medical history presented with generalized abdominal pain accompanied by Kehr's sign. He is diagnosed with ruptured spleen by contrast-enhanced computed tomography and successfully treated with splenectomy. He was discharged 6 days after surgery. Conclusions: Spontaneous rupture of the spleen is uncommon, but with high morbidity and mortality. It must be a differential diagnosis in the face of abdominal and/or chest pain, and the corresponding imaging studies should be carried out if the patient's conditions allow it, or their search during an exploratory laparotomy.

Introducción: la ruptura esplénica espontánea frecuentemente es mortal debido a la demora en el diagnóstico y tratamiento. Se puede presentar dolor abdominal, signo de Kehr, náuseas, distensión abdominal, alteración de la consciencia y obstrucción intestinal. En lesiones esplénicas más grandes, se presentan signos de peritonitis y shock hipovolémico. El estudio de elección es la tomografía computarizada contrastada. El diagnóstico se confirma por serología viral negativa y bazo normal en la inspección macroscópica e histopatológica. El tratamiento más frecuente es la esplenectomía. Caso clínico: paciente hombre de 30 años de edad, sin antecedentes patológicos, con dolor abdominal generalizado, acompañado del signo de Kehr. Es diagnosticado con ruptura de bazo por tomografía computarizada contrastada y tratado exitosamente con esplenectomía. Se egresa a los 6 días postquirúrgicos. Conclusiones: la ruptura espontánea del bazo es poco común, pero con alta morbimortalidad. Debe ser un diagnóstico diferencial ante un dolor abdominal y/o torácico, y realizar los estudios de imagen correspondientes si las condiciones del paciente lo permiten o bien su búsqueda durante una laparotomía exploratoria.

Spontaneous (idiopathic) rupture of the urinary bladder: a systematic review of case series and reports.

OBJECTIVES: To perform a systematic review of all cases of spontaneous rupture of the urinary bladder (SRUB) and to describe the demographic data, associated comorbidities, clinical presentation, diagnosis, relevant laboratory findings, associated factors, management, morbidity and mortality associated with the presentation of SRUB. METHODS: The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO). A search was carried out across the following electronic databases: PubMed, Web of Science, Scopus, Google Scholar and the Cochrane Database of Systematic Reviews. Full texts of selected studies were analysed, and data extracted. The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). RESULTS: A total of 278 articles comprising 240 case reports and 38 case series, with a total of 351 patients were included. The median (interquartile range [IQR]) age of all included patients was 47.5 (33-65) years. The median (IQR) time to presentation was 48 (24-96) h, with the major presenting symptom being abdominal pain (76%). In patients in whom the diagnosis was made prior to any intervention, the condition was misdiagnosed in 64% of cases. The diagnosis was confirmed during explorative open surgery in 42% of cases. Pelvic radiation (13%) and alcohol intoxication (11%) were the most common associated factors. Intraperitoneal rupture (89%) was much more common, with the dome of the bladder being most frequently involved (55%). The overall mortality was 15%. CONCLUSION: This review identified a number of key factors that appear to be associated with an increased incidence of SRUB. It also emphasized the high rate of misdiagnosis and challenge in confirming the diagnosis. Overall, it highlighted the importance of the need for increased awareness and maintaining a high index of suspicion for this condition.

Spontaneous rupture of an aneurysm of the superior thyroid artery: A rare cause of acute respiratory failure.

Ruptured aneurysm of superior thyroid artery is a very rare pathological event. Underlying causes such as trauma, malignancy or iatrogenic are not systematically found. Resulting cervical hematoma is life threatening and can lead to acute respiratory failure, dysphagia, vocal cord paralysis and hemomediastinum. Endovascular treatment combined with surgical drainage has been described as an effective treatment. In this case report, a 63-year-old man presented a spontaneous rupture of an aneurysm of superior thyroid artery resulting in cervical hematoma and acute respiratory failure.

The Importance of Nodule Size in the Management of Ruptured Thyroid Nodule After Radiofrequency Ablation: A Retrospective Study and Literature Review.

Background: Nodule rupture is a relatively uncommon yet severe complication of radiofrequency ablation (RFA). When nodule rupture occurs, determining suitable therapeutic management is a critical issue. A study herein aimed to identify the predictive factors affecting the management of post-RFA nodule rupture. Methods: Post-RFA nodule rupture data of 9 patients were enrolled from 2 medical centers. A literature investigation was performed, uncovering nodule rupture data of 17 patients. A total of 26 patients were analyzed and divided into two groups, categorized as patients requiring either invasive or conservative therapeutic management. Data including initial symptoms, imaging, therapeutic management, and prognosis were reviewed and compared between the two groups. Results: Significant differences in nodule diameter, and the ablation time of the course prior to rupture (RUP time) were noted between the two groups (p = 0.045 and 0.008, respectively). Logistic regression analysis indicated the initial nodule diameter and RUP time significantly affected the requirement of invasive treatment (OR 1.99 and 1.11, respectively). Considering practicality, when a nodule with an initial maximum diameter of >4.5cm ruptured, invasive management was suggested (sensitivity 69% and specificity 79%). Conclusion: Though nodule ruptures can be managed conservatively, a ruptured nodule with an initial maximum diameter of >4.5cm may require invasive management. Understanding the significant clinical and imaging features will help physicians make an appropriate risk assessment to determine the correct treatment in a timely manner.

Shock caused by spontaneous rupture uterine vessels during puerperal period: a case report and literature review.

Hemoperitoneum caused by spontaneous rupture of uterine vessels during delivery is relatively rare in obstetric hemorrhage, and even rarer during the puerperal period. It can be life-threatening without timely diagnosis and treatment; therefore, the literature on this topic is very scarce. To explore its etiology and identify its diagnosis and treatment principle, we are reporting a case of shock caused by spontaneous rupture of uterine vessels admitted in our hospital. Its etiology is still unknown, its presenting symptoms are commonly unspecific, and its diagnosis is often made during the surgery. The rupture of uterine vessels during pregnancy should be differentiated from placental abruption, uterine rupture, placenta implantation through the uterus, and abdominal organ rupture. Active and timely operative intervention can prevent the mortality. This case stresses the need for careful post-delivery monitoring for revealed postpartum hemorrhage. We will discuss possible etiologies of uterine vessels rupture during pregnancy, associated imaging findings, and management options.

Spontaneous rupture of a renal artery pseudoaneurysm in a hemodialysis patient: A case report.

RATIONALE: Renal artery pseudoaneurysm is a rare vascular lesion usually caused by trauma or percutaneous urological procedures. Spontaneous rupture of pseudoaneurysms without predisposing events, especially in hemodialysis patients, has rarely been reported. PATIENT CONCERNS: A 25-year-old man receiving maintenance hemodialysis visited the emergency room because of sudden severe right flank pain. He had no history of trauma or urological procedures except for a left renal biopsy to diagnose Alport syndrome 10 years prior. DIAGNOSIS: Contrast-enhanced computed tomography revealed a right perirenal hematoma with pseudoaneurysms. INTERVENTIONS: On renal angiography, multiple pseudoaneurysms were observed in the right renal artery branches and embolization was performed. OUTCOMES: Post-angiography showed no pseudoaneurysms. His abdominal pain improved, and he was discharged 2 weeks after embolization. LESSONS: When maintenance dialysis patients complain of severe abdominal pain, spontaneous rupture of a renal pseudoaneurysm should be considered as a differential diagnosis, even if the patient has no history of trauma or previous urological procedures.

The prognostic effects of hemodynamic parameters on rupture of intracranial aneurysm: A systematic review and meta-analysis.

BACKGROUND: Many risk factors are associated with rupture of intracranial aneurysm. However, the prognostic effects hemodynamic factors on intracranial aneurysm rupture remains poorly understood. A meta-analysis was performed based on contemporary studies to evaluate the prognostic effect of hemodynamic parameters on rupture of intracranial aneurysm. METHODS: The Cochrane Library, PubMed, Embase, and Web of Science were searched for cohort studies that analyzed hemodynamic parameters for intracranial aneurysm rupture prior to May 1, 2020. The standardized mean difference (SMD) and odds ratio (OR) with 95% confidence interval (CI) were calculated to assess the effect of individual hemodynamic parameters on intracranial aneurysm rupture. The primary outcomes were difference in wall shear stress (WSS), oscillatory shear index (OSI) and low shear index (LSA) between ruptured and unruptured intracranial aneurysm. Two reviewers independently assessed the quality of the trials and the associated data. All statistical analyses were performed using standard statistical procedures in Review Manager 5.2. RESULTS: A total of 15 studies including 779 patients with 900 aneurysms were identified for this meta-analysis. The pooled results indicated that the average WSS, OSI and LSA% had significant associations with rupture of intracranial aneurysm, with pooled SMDs of -0.36 (95% CI -0.57 to -0.15; P = 0.001), 0.37 (95% CI 0.19 to 0.55; P < 0.0001) and 0.57% (95% CI 0.18 to 0.95; P = 0.004), respectively. In addition, other hemodynamic parameters, including aneurysm size, aspect ratio, mean volume, undulation index, ellipticity index, nonsphericity index, number of vorticies, and relative residence time significant associations with intracranial aneurysm rupture. Multivariate analysis indicated that circumferential wall tension, angle btwn, irregular shape and size of aneurysms were independent risk factors of intracranial aneurysm rupture. CONCLUSIONS: This meta-analysis identified WSS, OSI and LSA% as influential hemodynamic parameters on rupture of intracranial aneurysm. The roles of other hemodynamic parameters and risk factors for intracranial aneurysm rupture need further assessments in future.

Preoperative Wilms tumor rupture in children.

PURPOSE: According to the guidelines of International Society of Pediatric Oncology (SIOP) and National Wilms Tumor Study (NWTS), Wilms tumor with preoperative rupture should be classified as at least stage III. Few clinical reports can be found about preoperative Wilms tumor rupture. The purpose of this study was to investigate our experience on the diagnosis, treatment and prognosis of preoperative Wilms tumor rupture. METHODS: Patients with Wilms tumor who underwent treatment according to the NWTS or SIOP protocol from January 2008 to September 2017 in Beijing Children's Hospital were reviewed retrospectively. The clinical signs of preoperative tumor rupture were acute abdominal pain, and/or fall of hemoglobin. The radiologic signs of preoperative tumor rupture are as follows: (1) retroperitoneal and/or intraperitoneal effusion; (2) acute hemorrhage located in the sub-capsular and/or perirenal space; (3) tumor fracture communicating with peritoneal effusion; (4) bloody ascites. Patients with clinical and radiologic signs of preoperative tumor rupture were selected. Patients having radiologic signs without clinical symptoms were also selected. The clinical data, treatments and outcomes were analyzed. Meanwhile, patients without preoperative Wilms tumor rupture during the same period were collected and analyzed. RESULTS: 565 Patients with Wilms tumor were registered in our hospital. Of these patients, 45 patients were diagnosed with preoperative ruptured Wilms tumor. All preoperative rupture were confirmed at surgery. Spontaneous tumor rupture occurred in 41 patients, the other 4 patients had traumatic history. Of the 45 patients, 41 were classified as stage III, 3 patients with pulmonary metastases were classified as stage IV, and one patient with bilateral tumors were classified as stage V. Of these patients with preoperative tumor rupture at stage III, 30 patients had clinical and radiologic signs of tumor rupture, the other 11 patients had radiologic signs without clinical symptoms. Among the 41 patients at stage III, 13 patients had immediate surgery without preoperative chemotherapy (immediate group), and 28 patients had delayed surgery after preoperative chemotherapy (delayed group). In immediate group, 12 patients had localized rupture, 1 patient underwent emergency surgery because of continuous bleeding. In delayed group, 4 had inferior vena cava tumor embolus (1 thrombus extended to inferior vena cava behind the liver, three thrombi got to the right atrium), 4 crossed the midline with large tumors, 20 had extensive rupture without localization. In immediate group, tumor recurrence and metastasis developed in 2 patients, and no death occurred. In the delayed group, tumor recurrence and metastasis developed in 8 patients, and 7 patients died. During the same period, 41 patients were classified as stage III without preoperative rupture. In the non-ruptured group, tumor recurrence and metastasis developed in 3 patients, and 4 patients died. The median survival time in the ruptured group (both immediate group and delayed group) and non-ruptured group were (85.1 ± 7.5) and (110.3 ± 5.6) months, and the 3-year cumulative survival rates were 75.1% and 89.6%, respectively. The overall survival rate between the ruptured and non-ruptured groups showed no statistic difference (P = 0.256). However, there was significant difference in recurrence or metastasis rate between the ruptured and non-ruptured groups (24.4% vs 7.3%; P = 0.031). CONCLUSION: Contrast-enhanced computed tomography (CT) and ultrasonography (US) are of major value in the diagnosis of preoperative tumor rupture, and immediate surgery or delayed surgery are available therapeutic methods. The treatment plan was based on patients' general conditions, tumor size, position and impairment degree of tumor rupture, extent of invasion and experience of a multidisciplinary team (including surgeon and anesthesiologists). In our experience, for ruptured preoperative tumor diagnosed with stage III, the criteria for immediate surgery are as follows: tumor not acrossing the midline, tumor without inferior vena cava thrombus, localized rupture, being capable of complete resection. Selection criteria for delayed surgery after preoperative chemotherapy are as follows: large tumors, long inferior vena cava tumor thrombus, tumors infiltrating to surrounding organs, unlocalized rupture, tumors can not being resected completely. Additionally, patients with preoperative Wilms tumor rupture had an increased risk of postoperative recurrence or metastasis.

Ruptured functioning adrenal tumour, atypical presentation with renal colic and hypertension.

Pheochromocytomas are uncommon tumours that originate in chromaffin cells. They are a representation of 0.1%-1% of all cases of secondary hypertension. Most pheochromocytomas are unilateral and benign, featuring catecholamine production, as well as the production of other neuropeptides. Pheochromocytomas are mostly located in the adrenal gland; the frequency of occurrence is highest between 30 and 50 years of age; however, up to 25% of cases may be linked to multiple endocrine neoplasia type 2, Von-Hippel-Landau disease and type 1 neurofibromatosis in the young.We present a case of ruptured left adrenal pheochromocytoma with an atypical presentation. A 30-year-old male patient presented with severe left flank pain and hypertension. The CT scan of the abdomen showed bleeding from the left adrenal mass, where resuscitation and angioembolisation were done. Embolisation of the inferior and superior arteries was done, but the middle failed. The patient experienced a significant drop in haemoglobin and a haemorrhagic shock post angioembolisation, which called for emergency laparotomy. The patient is currently doing well with an uneventful postoperative course.

Falciform ligament abscess secondary to a ruptured liver abscess in a child: a case report.

Abscess of the liver ligaments is extremely rare, and abscess of the falciform ligament has been sporadically reported. We report the case of a 3 years old male who presented with a three days history of right upper quadrant abdominal pain, fever and nausea. The ultrasound and computed tomography (CT) scan showed an abdominal wall abscess located anterior to the liver. The patient underwent surgery. Abscess of the falciform ligament secondary to a ruptured liver abscess was found. Excision of the falciform ligament including the abscess was performed. Although pathology of the falciform ligament is rare, it should be included in the differential diagnosis of acute abdomen.

Outcomes of Small Renal Artery Targets in Patients Treated by Fenestrated-Branched Endovascular Aortic Repair.

OBJECTIVE: The aim was to evaluate renal related outcomes in patients who had incorporation of a small (<4.0 mm) renal artery (RA) during fenestrated-branched endovascular aortic repair (F-BEVAR). METHODS: A total of 215 consecutive patients enrolled in a prospective F-BEVAR trial were reviewed. Computed tomography angiography centreline of flow reconstruction was used to measure mean RA diameter. Patients who had at least one <4.0 mm main or accessory RA incorporated by fenestration or directional branch (study group) were compared with patients who had incorporation of two ≥5.0 mm RAs (control group). Endpoints were technical success of RA incorporation, RA rupture and kidney loss, primary and secondary RA patency, RA branch instability and re-interventions, and renal function deterioration. RESULTS: Twenty-four patients with 28 <4.0 mm RAs (16 accessory and 12 main RAs) were compared with 144 patients with 288 ≥5.0 mm incorporated RAs. Study group patients were significantly younger than controls (72 ± 8 vs. 75 ± 8 years, p = .04) and more often females (46% vs. 21%, p = .018); there were no differences in cardiovascular risk factors and aneurysm extent. Technical success was 92% for <4.0 mm and 99% for ≥5.0 mm RA incorporation (p = .05). Inadvertent RA rupture occurred in three patients in the study group (13%) and in one (1%) in the control group (p = .009) resulting in kidney loss in two study group patients (8%) and one (1%) control group patient (p = .05). At one year, primary patency was 79 ± 9% vs. 94 ± 1% (p < .001) and secondary patency was 84 ± 8% vs. 97 ± 1% (p < .001) for study vs. control group; freedom from branch instability was 79 ± 9% vs. 93 ± 2% (p = .005), respectively. There were no differences in re-intervention rates and renal function deterioration between the groups. The mean follow up time was 21 ± 14 months. CONCLUSION: Incorporation of <4.0 mm RAs during F-BEVAR is associated with lower technical success, higher risk of arterial disruption and kidney loss, and lower patency rates at one year.

Deceased donor kidney transplant complicated by spontaneous rupture of native kidney in a HIV patient.

Spontaneous native kidney rupture (SNKR) is a rare occurrence, commonly associated with underlying renal tumors or acquired renal cystic disease in both the kidney transplant (KT) and non-KT populations. Herein, we present a 65-year-old African American man who experienced a non-malignant SNKR 6 days after a deceased donor KT and underwent emergent native nephrectomy. The patient's hospital course was complicated by thrombocytopenia and refractory hypertension. He experienced delayed graft function and was maintained on hemodialysis until post-operative day 30. This case demonstrates an unusual presentation of SNKR in the immediate post-KT setting and illustrates the clinical decision-making algorithm.

Spontaneous rupture of the renal calyx secondary to a vesicoureteral junction calculus.

BACKGROUND: Spontaneous urinary collecting system rupture is caused by increased ureteral intraluminal pressure secondary to an obstruction. Rarely, a small stone exerts high intraureteral pressure especially if it is located distally. Many management modalities with good outcomes have been implicated. PURPOSE: Herein, we present a case of nontraumatic rupture of the renal calyx due to a 4 mm obstructing stone at the vesicoureteral junction. BASIC PROCEDURES: CT scan of abdomen and pelvis without contrast, CT scan of the abdomen and pelvis with intravenous contrast, Cystoscopy, Double-J ureter stent, Urinary Foley catheter. MAIN FINDINGS: The diagnosis was confirmed by CT imaging. Non-contrast enhanced CT scan of abdomen and pelvis showed obstructive calculi measuring 4 mm in the right vesicoureteral junction. Contrast-enhanced CT scan revealed leakage of contrast in the perinephric space at the right major calyx with intact bilateral ureters, suggestive of calyceal rupture. The treatment involved antibiotics and double-J stenting. PRINCIPAL CONCLUSIONS: This case demonstrates that spontaneous calyceal rupture should be suspected in urolothiasis patients presenting for a severe pain even if the calculus is small (less than 5 mm) and the laboratory markers are normal. An immediate management is required to relief symptoms and prevent further complications.

Repeated episodes of thoracic empyema after spontaneous esophageal rupture.

A 52-year-old man with a cough, high fever, and inappetence was diagnosed with thoracic empyema on computed tomography at a local hospital. He had undergone continuous thoracic drainage for a spontaneous esophageal rupture that occurred 17 years earlier. He developed left thoracic empyema 2, 14 and 17 years following the initial esophageal rupture that improved with conservative therapy each time. The most recent episode of thoracic empyema also resolved with conservative therapy. However, he was referred to our hospital for further examination and more complete surgical treatment for recurrent thoracic empyema. Gastrointestinal endoscopy showed a scar from the previous esophageal rupture in the lower esophagus. We considered that recurrent esophageal rupture may have caused repeated episodes of thoracic empyema based on endoscopic findings and his past history and elected to perform subtotal esophagectomy to provide a complete cure. A left transthoracic esophagectomy with a left lower lung lobectomy and gastric tube reconstruction via a retrosternal route were performed. A latissimus dorsi muscle flap was used to eliminate the dead space after lower lung lobectomy to prevent recurrent thoracic empyema. The bronchial stump was covered with a pedicled intercostal muscle flap to prevent leakage from the stump. Minor leakage from the esophagogastrostomy site developed during the postoperative course but resolved with conservative therapy. The patient was transferred to the previous hospital on the 36th postoperative day. Four years after surgery, he had good oral intake and nutritional status without any evidence of recurrent thoracic empyema.