Spontaneous splenic hemorrhage in a patient on apixiban

Novel oral anticoagulants (NOACs) are increasingly popular. Spontaneous splenic rupture is rare and life-threatening, especially if it is not immediately recognized. Prior work has demonstrated an association with NOAC use and spontaneous splenic rupture in unusual clinical circumstances. We present the case of spontaneous splenic hemorrhage in a largely healthy 57-year old female who was recently started on apixiban for a provoked PE. She had been discharged from an outside facility, and presented just hours after discharge to our emergency department in extremis: unconscious, pale, hypotensive, and tachycardic. Her abdomen on arrival was noted to be distended with positive fluid wave, and bedside ultrasound confirmed massive peritoneal fluid. Prompt diagnostic peritoneal aspirate confirmed hemoperitoneum, and a massive transfusion protocol was initiated. The patient's blood pressure and heart rate improved, and she was stabilized for imaging. Computed tomography demonstrated large subcapsular splenic hematoma with active extravasation at the periphery of the spleen. The patient was taken emergently to interventional radiology suite where splenic artery embolization was performed and an IVC filter was placed. She subsequently developed acute respiratory distress syndrome and persistent low urine output with hypotension despite resuscitation, and was taken to the operating room for splenectomy and abdominal washout. She improved thereafter and was discharged 12 days later. Prompt diagnosis and aggressive early resuscitation contributed to this patient's outcome.