Background

We report the case of splenic rupture after initiation of anticoagulation for splenic vein thrombus. A 57-year-old female with multiple medical problems not limited to a history of depression, irritable bowel syndrome, mixed connective tissue disease, osteoarthritis and obesity with BMI of 55 underwent an uncomplicated robotic-assisted sleeve gastrectomy. She was re-admitted on post-operative day seventeen with diarrhea, chest and abdominal pain, and poor tolerance of her diet. CT scan with IV contrast showed a splenic vein thrombus causing a large splenic infarct. She was started on therapeutic low molecular weight heparin and was monitored for improvement in her symptoms. Four days later she had an acute change in mental status with associated hypotension and tachycardia requiring transfer to the intensive care unit. Repeat cross-sectional imaging showed concern for large volume hemoperitoneum with extravasation of contrast from the spleen. She was taking urgently for exploration and underwent laparotomy with splenectomy. Intraoperatively the spleen was noted to be ruptured into multiple pieces. Evaluation of the gastric sleeve via upper endoscopy and leak test was negative for any pathology. A surgical drain was left in the splenic bed and a post-pyloric dobhoff feeding tube was placed. Portal-splenic-mesenteric vein thrombus is a known rare complication after sleeve gastrectomy, however spontaneous splenic rupture after initiation of therapeutic anticoagulation has not been reported in the bariatric literature.