“I don’t know,” the radiologist replied. “Never seen anything like it.”
“Guess there’s only one way to find out,” Don concluded.
everyone crowded in to see the image. The scan showed blood everywhere.
What we saw suggested an aneurysm—a malformation of a blood vessel, an uncommon but devilish ailment. Most stem from genetically influenced defects in proteins of the arterial wall. Aneurysms, which bulge like a balloon squeezed too tightly, often arise at an artery’s branching point, though they can pop up anywhere. Until they burst without warning, they can escape diagnosis because the irritation caused by blood mimics that of a common infection or even a migraine. In adults 30 to 60 years old, aneurysms rupture most frequently in the brain, causing tens of thousands of fatal or disabling hemorrhages each year. Women are particularly vulnerable. The abdominal aorta, for its part, can bulge out and burst anywhere, but only rarely does this happen in someone under 55.
Then there are the odd ducks, like splenic artery aneurysms. The spleen lies under the left diaphragm, behind the ninth, tenth, and eleventh ribs. It’s like the body’s oil filter, trapping old red blood cells and certain types of bacteria and removing them from circulation. Unfortunately, the spleen’s good-size artery is at risk for an aneurysm during pregnancy, particularly in the third trimester, when the enlarging uterus presses on the vessel, increasing its blood pressure. I know of four cases of ruptured splenic artery aneurysms in pregnant women, each presenting as upper-abdominal pain and vomiting in the third trimester. Flummoxed doctors mistook them for stomach viruses—until the patients’ blood pressure plummeted. Two of the women died; the others were saved by last-minute surgery.
Don’t fret too much about your plumbing, though. We Homo sapiens are well-put-together organisms. Blowing a gasket is a rare event. However, given that the body will do everything possible to keep blood pressure up, a sudden drop should, in this age of bedside ultrasound, prompt a quick look at the plumbing. There is no easier way to save a life.
Three hours later, Don swung by the emergency room, digital camera in hand. “It was a bulge, like an aneurysm, where the artery enters the spleen,” he told me, clicking through photos of the crescent-shaped maroon organ. “Splenic peliosis. Ridiculously rare. Cause unknown. Good thing we had the CT scan. Getting through all the adhesions from the gastric bypass surgery was tough, but at least we knew where to go. Luckily for him, it had partly clotted.
“Oh, and you know why the belly wasn’t tender?” he continued. “Adhesions from the gastric bypass had stuck his intestines up against the abdominal wall, forcing the blood to the sides. So even with a belly full of blood, it seemed like a benign exam.”
“Whew,” I whistled. “Close one.”
Two days later, Mr. Dexter was holding court in the intensive care unit. “So, should I play the lottery, doctor? They tell me I’m a million-to-one shot,” he joked. He looked so healthy I wanted to click my heels.
“No need for that. We already won,” I told him. “You are the jackpot.”
Tony Dajer is director of emergency medicine at New York Downtown Hospital in Manhattan. The cases described in Vital Signs are real, but names and certain details have been changed.
