When Minor Trauma Leads to Major Surgery: Splenic Cyst Rupture Requiring Emergency Splenectomy After Failed Conservative Management in a 15-Year-Old Boy

When Minor Trauma Leads to Major Surgery: Splenic Cyst Rupture Requiring Emergency Splenectomy After Failed Conservative Management in a 15-Year-Old Boy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report When Minor Trauma Leads to Major Surgery: Splenic Cyst Rupture Requiring Emergency Splenectomy After Failed Conservative Management in a 15-Year-Old Boy Abdullah Awad, Abdelfattah Eldibany, Mohannad Alnajjar, Mostafa Abdelmaksod This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8808711/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction : splenic cysts are uncommon in pediatric patients and mostly asymptomatic and incidentally discovered but may present with abdominal discomfort. Large cyst may rupture after minor trauma leading to life-threatening hemorrhage. Splenic preserving measuring is the main goal of management for pediatrics, however life-saving splenectomy is crucial in critical conditions. Case presentation : We have reported a case of 15-years-old who experienced trivial abdominal trauma leading to hemoperitoneum due to rupture splenic cyst confirmed with contrast-enhanced CT abdomen and pelvis. After resuscitation and failure of conservative management, splenectomy was performed uneventually and patient was discharge in a stable condition. This case highlights the diagnostic and management challenges associated with splenic cyst rupture in an adolescent patient. General Surgery splenic cyst epidermoid cyst splenic rupture splenectomy conservative management Figures Figure 1 Figure 2 1. Introduction Splenic cysts are uncommon types of splenic lesion, making up about 0.07–0.3% of all splenic pathologies. ( 1 , 2 ) They can be of two types: parasitic or non-parasitic. Non-parasitic cysts are further divided into primary and secondary. Primar cysts have a layer of epithelial cells, like epidermoid, dermoid and mesothelial cysts, or endothelial cells, such as hemangioma or lymphangioma. Secondary cysts called pseudocysts, are not covered with cells and usually developed after an injury. ( 3 , 4 ) Non-parasitic primary splenic cysts are considered congenital and make up around 10% of all splenic cysts. ( 5 ) Splenic cysts can cause various symptoms, from asymptomatic at all to pain or fullness at the left flank. Moreover, large cysts can cause pressure on the nearby organs. ( 6 ) Traditionally, surgery was the main treatment. ( 7 ) But recently, interventional radiological techniques have started to be evolved. ( 8 ) Epidermoid cysts are the most common types of congenital cysts found in the spleen. ( 9 ) The exact case in unknown, but previous case reports and research all agree that epidermoid splenic cysts are congenital, primary, nontraumatic, benign cysts. ( 7 , 10 – 12 ) Most epidermoid spleen tumors are asymptomatic and found incidentally in children or teenagers with a female predilection. However, they can sometimes cause symptoms due to compression, infection, injury or bleeding. ( 13 ) 2. Case presentation A 15-year-old boy with a previous history of intermittent mild thrombocytopenia during recurrent attacks of chest infections not mandating any medical treatment, presented with abdominal pain and hemodynamic instability following trivial blunt trauma to the left side of his abdomen while playing football. Physical examination revealed tachycardia up to 120 beats per minutes with normal blood pressure and left upper quadrant bruising associated with abdominal distension and all-over abdominal tenderness mainly in the left hypochondrium. Focused Assessment with Sonography for Trauma (FAST) demonstrated hemoperitoneum specially around the spleen, accordingly resuscitation was done according to ATLS protocol by intravenous fluids, packed RBCS transfusion and tranexamic acid. Contrast-enhanced computed tomography of abdomen & pelvis (Fig. 1 ) revealed a large irregular cystic lesion (9.5 x 14 x 18.3 cm) at the splenic hilum with wall discontinuity involving the lower medial aspect of this lesion and surrounding free fluid. After primary resuscitation at the emergency department, the patient showed signs of stability, as a result decision of conservative management had been made, via admission in ICU for close monitory, intravenous fluid therapy and serial clinical examination with serial Hgb monitoring. However, Four-hours later, the patient experienced tachycardia up to 130 beats per minutes associated with mild respiratory distress and progressive abdominal distension, but the Hgb level did not show any drop. Upon those findings, life-saving exploratory laparotomy was decided. Intraoperative findings of a ruptured large splenic cyst at the hilum with massive hemoperitoneum consisting of mixed cyst fluid and blood, without any identified intra-abdominal organ injuries. Accordingly, splenectomy was done (Fig. 2 ), with insertion of 15 F hemovac drain at the splenic bed. The procedure was completed uneventually, and the patient transferred to ICU for 1 day for postoperative monitoring, followed by 3 days in regular surgical ward then was discharged in a stable state after removal of his abdominal drain. He received post-splenectomy triple vaccine 2 weeks later in the outpatient clinic. Histopathological assessment of the excised spleen showed splenic large cystic cavity with irregular walls and areas of hemorrhage. While the microscopic examination showed a benign squamous epithelium–lined cyst consistent with an epidermoid cyst, with areas of calcification, fibrosis, hemorrhage, and cholesterol clefts. Three reactive lymph nodes were identified, and the specimen was negative for malignancy. 3. Discussion Most splenic cysts are secondary or false cysts (table 1), often caused by trauma or infection. True splenic cysts are quite rare and make up less than 10% of all cysts found in the spleen. Among the true cysts, epidermoid cysts are the most common type that is present since birth, these usually appear in children and young adults. They have a lining of squamous epithelium and may contain keratin, cholesterol crystals and areas of calcification or fibrous. Epidermoid cysts are considered primary congenital cysts with unclear origin, but some studies suggests that during embryogenesis, these cysts may form when peritoneal mesothelial cells fold into the splenic parenchyma. ( 14 ) Primary cysts (true) Secondary cysts (false) Parasitic Post-traumatic Echinococcus Splenic infarct Non-parasitic Congenital Neoplastic Lymphoma Metastasis Table-1 : Classification of splenic cysts according to Fowler, 1978 ( 15 ) Epidermoid cysts often do not cause any symptoms, but sometimes leads to abdominal pain, a feeling of fullness, or complications such as infection, rupture or hemorrhage. Larger cysts, especially larger than 5 cm are more likely to rupture even from trivial trauma because the surrounding spleen tissue become thinner and the intracystic pressure increases. The symptoms of splenic cysts are non-specific, patient with small cysts usually asymptomatic; however, symptoms tend to appear when the cysts get quite larger and sometimes after a minor injury causing intracystic hemorrhage. Patients often report a mass feeling or pain in the abdomen, which can be in different areas but commonly felt in the upper left part of the abdomen. Postprandial discomfort or dull aches because the stomach is being pressed. Occasionally, urinary symptoms and left flank pain may occur due to cyst pressure on the kidney or the ureter. Cyst compression on thoracic viscera my cause dyspnea, respiratory infection or tachycardia. ( 16 ) CT Typically shows a hypoattenuating relatively well-defined intrasplenic lesion. The wall is thin and has a sharp demarcation to the splenic parenchyma. There is no rim or internal enhancement. Wall calcification may be present. ( 17 ) Conservative management of splenic trauma is widely accepted in hemodynamically stable patients, especially in children, to preserve splenic function. However, in cases involving pre-existing pathology (such as cysts), the risk of delayed rupture or re-bleeding is higher. The failure of conservative management in this case underscores the importance of early surgical intervention when hemodynamic instability develops. Histopathological confirmation of an epidermoid cyst is essential, as radiologic features may overlap with parasitic cysts or pseudocysts. The presence of squamous epithelial lining, fibrosis, calcifications, and absence of malignant changes confirm its benign congenital nature. ( 18 ) In this case, the patient’s history of intermittent thrombocytopenia may have been related to hypersplenism caused by the large cyst and experienced easy fatigability with exercise. The trivial mechanism of injury highlights the vulnerability of cystic spleens to rupture. After failure of the trial of conservative management, exploratory laparotomy and splenectomy were performed. The histopathological assessment confirmed rupture splenic epidermal cyst. The postoperative period passed uneventually, and the patient was discharged in a stable state. Learning Points : Even minor trauma can cause rupture of large splenic cysts, especially congenital large epidermoid types. Conservative management of splenic trauma should be cautiously pursued when pre-existing splenic pathology is present. Rapid deterioration warrants immediate surgical intervention. Post-splenectomy vaccination and long-term infection prevention counseling are critical in pediatric patients. 4. Conclusion This case illustrates that even minor blunt abdominal trauma can result in catastrophic rupture of a large congenital epidermoid splenic cyst. Early recognition, close monitoring, and readiness to escalate from conservative to surgical management are essential for optimal outcomes. Declarations Statement on Participant Consent to Publish An informed consent was obtained from the patient’s parents/legal guardians for participation in this study and for the publication of the clinical details and any accompanying images. Patient anonymity has been preserved in accordance with ethical standards. Conflicts of Interest The authors declare no conflicts of interest. References Hammouda SB, Mabrouk S, Bellalah A, Maatouk M, Zakhama A, Njim L (2022) Large splenic epithelial cyst: A rare presentation. Int J Surg Case Rep 95:107201 Senn AS, Bauer RC, Heigl A, Rosenberg R (2022) 23-year old man with a long history of abdominal pain, nausea and vomiting: Case report of a splenic cyst. Int J Surg Case Rep 93:106991 Macheras A, Misiakos EP, Liakakos T, Mpistarakis D, Fotiadis C, Karatzas G (2005) Non-parasitic splenic cysts: a report of three cases. World J Gastroenterol 11(43):6884–6887 Sadeghi A, Naderpour Z, Ebrahimpur M, Saffar H (2017) Non-parasitic Splenic Cyst. Middle East J Dig Dis 9(4):242–243 Shukla RM, Mukhopadhyay M, Mandal KC, Mukhopadhyay B (2010) Giant congenital infected splenic cyst: An interesting case report and review of the literature. Indian J Surg 72(3):260–262 Hansen MB, Moller AC (2004) Splenic cysts. Surg Laparosc Endosc Percutan Tech 14(6):316–322 Rana AP, Kaur M, Singh P, Malhotra S, Kuka AS (2014) Splenic epidermoid cyst - a rare entity. J Clin Diagn Res 8(2):175–176 Lopez JJ, Lodwick DL, Cooper JN, Hogan M, King D, Minneci PC (2017) Sclerotherapy for splenic cysts in children. J Surg Res 219:1–4 Tassopoulos A, Wein M, Segura A (2017) Traumatic rupture of a giant congenital splenic cyst presenting as peritonitis. Radiol Case Rep 12(2):401–404 Grover S, Garg B, Sood N, Singh S (2016) Splenic Epidermoid Cyst in a Five-Year-Old Child. J Clin Diagn Res 10(7):ED07–9 Vuyyuru S, Kharbutli B (2017) Epidermoid cyst of the spleen, a case report. Int J Surg Case Rep 35:57–59 Thomas M, Taiwo B (1994) Splenic epidermoid cysts presenting as an acute abdomen. Postgrad Med J 70(823):376–377 Da Costa C, Gaujoux S, Gouya H, Dousset B, Legmann P (2015) Epidermoid splenic cyst. Diagn Interv Imaging 96(4):417–420 Morgenstern L (2002) Nonparasitic splenic cysts: pathogenesis, classification, and treatment. J Am Coll Surg 194(3):306–314 Fowler RH (1953) Nonparasitic benign cystic tumors of the spleen. Int Abstr Surg 96(3):209–227 Shabtaie SA, Hogan AR, Slidell MB (2016) Splenic Cysts Pediatr Ann 45(7):e251–e256 Shirkhoda A, Freeman J, Armin AR, Cacciarelli AA, Morden R (1995) Imaging features of splenic epidermoid cyst with pathologic correlation. Abdom Imaging 20(5):449–451 Gianom D, Wildisen A, Hotz T, Goti F, Decurtins M (2003) Open and laparoscopic treatment of nonparasitic splenic cysts. Dig Surg 20(1):74–78 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8808711","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":587081358,"identity":"cf9f4494-60ae-4c7d-95ce-dd1ed411bedc","order_by":0,"name":"Abdullah Awad","email":"","orcid":"","institution":"Alsalama Hospital, Jeddah, KSA","correspondingAuthor":false,"prefix":"","firstName":"Abdullah","middleName":"","lastName":"Awad","suffix":""},{"id":587081359,"identity":"258ca00d-a50c-4a2e-9268-3ac0cf06c0db","order_by":1,"name":"Abdelfattah Eldibany","email":"","orcid":"","institution":"Alsalama Hospital, Jeddah, KSA","correspondingAuthor":false,"prefix":"","firstName":"Abdelfattah","middleName":"","lastName":"Eldibany","suffix":""},{"id":587081360,"identity":"c8fd4e56-7c13-442d-ab06-1b66d2522a54","order_by":2,"name":"Mohannad Alnajjar","email":"","orcid":"","institution":"Alsalama Hospital, Jeddah, KSA","correspondingAuthor":false,"prefix":"","firstName":"Mohannad","middleName":"","lastName":"Alnajjar","suffix":""},{"id":587081361,"identity":"216d7804-fe34-4115-b4f0-521f97cf4167","order_by":3,"name":"Mostafa Abdelmaksod","email":"data:image/png;base64,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","orcid":"https://orcid.org/0009-0005-5644-1811","institution":"Alsalama Hospital, Jeddah, KSA","correspondingAuthor":true,"prefix":"","firstName":"Mostafa","middleName":"","lastName":"Abdelmaksod","suffix":""}],"badges":[],"createdAt":"2026-02-06 15:23:25","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8808711/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8808711/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102339619,"identity":"efa5b744-3ec5-4c3f-b20f-624e9c211b50","added_by":"auto","created_at":"2026-02-10 16:33:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":937327,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure-1:\u003c/strong\u003e Contrast-enhanced CT abdomen and pelvis showing rupture large splenic cystic lesion with surrounding free fluid\u003c/p\u003e","description":"","filename":"Screenshot20260206at6.27.59PM.png","url":"https://assets-eu.researchsquare.com/files/rs-8808711/v1/3ba8861365fdb9f654ec5e11.png"},{"id":102339620,"identity":"2da34af3-3220-4549-a888-010f1d1fa2ba","added_by":"auto","created_at":"2026-02-10 16:33:26","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":933248,"visible":true,"origin":"","legend":"\u003cp\u003eFigure-2: operative findings: ruptured huge splenic cyst\u003c/p\u003e","description":"","filename":"Screenshot20260206at6.28.15PM.png","url":"https://assets-eu.researchsquare.com/files/rs-8808711/v1/cde79893a212b9458e914743.png"},{"id":102339653,"identity":"39c74f62-7fd4-4e91-a181-1a9e82e0eb15","added_by":"auto","created_at":"2026-02-10 16:33:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2578658,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8808711/v1/184c7472-bf1b-4c99-8a61-0219d93d2fdc.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eWhen Minor Trauma Leads to Major Surgery: Splenic Cyst Rupture Requiring Emergency Splenectomy After Failed Conservative Management in a 15-Year-Old Boy\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eSplenic cysts are uncommon types of splenic lesion, making up about 0.07\u0026ndash;0.3% of all splenic pathologies. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) They can be of two types: parasitic or non-parasitic. Non-parasitic cysts are further divided into primary and secondary. Primar cysts have a layer of epithelial cells, like epidermoid, dermoid and mesothelial cysts, or endothelial cells, such as hemangioma or lymphangioma. Secondary cysts called pseudocysts, are not covered with cells and usually developed after an injury. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Non-parasitic primary splenic cysts are considered congenital and make up around 10% of all splenic cysts. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Splenic cysts can cause various symptoms, from asymptomatic at all to pain or fullness at the left flank. Moreover, large cysts can cause pressure on the nearby organs. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Traditionally, surgery was the main treatment. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) But recently, interventional radiological techniques have started to be evolved. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eEpidermoid cysts are the most common types of congenital cysts found in the spleen. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) The exact case in unknown, but previous case reports and research all agree that epidermoid splenic cysts are congenital, primary, nontraumatic, benign cysts. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) Most epidermoid spleen tumors are asymptomatic and found incidentally in children or teenagers with a female predilection. However, they can sometimes cause symptoms due to compression, infection, injury or bleeding. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e"},{"header":"2. Case presentation","content":"\u003cp\u003eA 15-year-old boy with a previous history of intermittent mild thrombocytopenia during recurrent attacks of chest infections not mandating any medical treatment, presented with abdominal pain and hemodynamic instability following trivial blunt trauma to the left side of his abdomen while playing football.\u003c/p\u003e \u003cp\u003ePhysical examination revealed tachycardia up to 120 beats per minutes with normal blood pressure and left upper quadrant bruising associated with abdominal distension and all-over abdominal tenderness mainly in the left hypochondrium. Focused Assessment with Sonography for Trauma (FAST) demonstrated hemoperitoneum specially around the spleen, accordingly resuscitation was done according to ATLS protocol by intravenous fluids, packed RBCS transfusion and tranexamic acid. Contrast-enhanced computed tomography of abdomen \u0026amp; pelvis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) revealed a large irregular cystic lesion (9.5 x 14 x 18.3 cm) at the splenic hilum with wall discontinuity involving the lower medial aspect of this lesion and surrounding free fluid.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter primary resuscitation at the emergency department, the patient showed signs of stability, as a result decision of conservative management had been made, via admission in ICU for close monitory, intravenous fluid therapy and serial clinical examination with serial Hgb monitoring. However, Four-hours later, the patient experienced tachycardia up to 130 beats per minutes associated with mild respiratory distress and progressive abdominal distension, but the Hgb level did not show any drop. Upon those findings, life-saving exploratory laparotomy was decided.\u003c/p\u003e \u003cp\u003eIntraoperative findings of a ruptured large splenic cyst at the hilum with massive hemoperitoneum consisting of mixed cyst fluid and blood, without any identified intra-abdominal organ injuries. Accordingly, splenectomy was done (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), with insertion of 15 F hemovac drain at the splenic bed. The procedure was completed uneventually, and the patient transferred to ICU for 1 day for postoperative monitoring, followed by 3 days in regular surgical ward then was discharged in a stable state after removal of his abdominal drain. He received post-splenectomy triple vaccine 2 weeks later in the outpatient clinic.\u003c/p\u003e \u003cp\u003eHistopathological assessment of the excised spleen showed splenic large cystic cavity with irregular walls and areas of hemorrhage. While the microscopic examination showed a benign squamous epithelium\u0026ndash;lined cyst consistent with an epidermoid cyst, with areas of calcification, fibrosis, hemorrhage, and cholesterol clefts. Three reactive lymph nodes were identified, and the specimen was negative for malignancy.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"3. Discussion","content":"\u003cp\u003eMost splenic cysts are secondary or false cysts (table 1), often caused by trauma or infection. True splenic cysts are quite rare and make up less than 10% of all cysts found in the spleen. Among the true cysts, epidermoid cysts are the most common type that is present since birth, these usually appear in children and young adults. They have a lining of squamous epithelium and may contain keratin, cholesterol crystals and areas of calcification or fibrous. Epidermoid cysts are considered primary congenital cysts with unclear origin, but some studies suggests that during embryogenesis, these cysts may form when peritoneal mesothelial cells fold into the splenic parenchyma. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary cysts (true)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary cysts (false)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParasitic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-traumatic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEchinococcus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSplenic infarct\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-parasitic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCongenital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoplastic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymphoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetastasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cb\u003eTable-1\u003c/b\u003e: Classification of splenic cysts according to Fowler, 1978 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEpidermoid cysts often do not cause any symptoms, but sometimes leads to abdominal pain, a feeling of fullness, or complications such as infection, rupture or hemorrhage. Larger cysts, especially larger than 5 cm are more likely to rupture even from trivial trauma because the surrounding spleen tissue become thinner and the intracystic pressure increases. The symptoms of splenic cysts are non-specific, patient with small cysts usually asymptomatic; however, symptoms tend to appear when the cysts get quite larger and sometimes after a minor injury causing intracystic hemorrhage. Patients often report a mass feeling or pain in the abdomen, which can be in different areas but commonly felt in the upper left part of the abdomen. Postprandial discomfort or dull aches because the stomach is being pressed. Occasionally, urinary symptoms and left flank pain may occur due to cyst pressure on the kidney or the ureter. Cyst compression on thoracic viscera my cause dyspnea, respiratory infection or tachycardia. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCT Typically shows a hypoattenuating relatively well-defined intrasplenic lesion. The wall is thin and has a sharp demarcation to the splenic parenchyma. There is no rim or internal enhancement. Wall calcification may be present. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) Conservative management of splenic trauma is widely accepted in hemodynamically stable patients, especially in children, to preserve splenic function. However, in cases involving pre-existing pathology (such as cysts), the risk of delayed rupture or re-bleeding is higher. The failure of conservative management in this case underscores the importance of early surgical intervention when hemodynamic instability develops. Histopathological confirmation of an epidermoid cyst is essential, as radiologic features may overlap with parasitic cysts or pseudocysts. The presence of squamous epithelial lining, fibrosis, calcifications, and absence of malignant changes confirm its benign congenital nature. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn this case, the patient\u0026rsquo;s history of intermittent thrombocytopenia may have been related to hypersplenism caused by the large cyst and experienced easy fatigability with exercise. The trivial mechanism of injury highlights the vulnerability of cystic spleens to rupture. After failure of the trial of conservative management, exploratory laparotomy and splenectomy were performed. The histopathological assessment confirmed rupture splenic epidermal cyst. The postoperative period passed uneventually, and the patient was discharged in a stable state.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLearning Points\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eEven minor trauma can cause rupture of large splenic cysts, especially congenital large epidermoid types.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eConservative management of splenic trauma should be cautiously pursued when pre-existing splenic pathology is present.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRapid deterioration warrants immediate surgical intervention.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePost-splenectomy vaccination and long-term infection prevention counseling are critical in pediatric patients.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"4. Conclusion","content":"\u003cp\u003eThis case illustrates that even minor blunt abdominal trauma can result in catastrophic rupture of a large congenital epidermoid splenic cyst. Early recognition, close monitoring, and readiness to escalate from conservative to surgical management are essential for optimal outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eStatement on Participant Consent to Publish An informed consent was obtained from the patient\u0026rsquo;s parents/legal guardians for participation in this study and for the publication of the clinical details and any accompanying images. Patient anonymity has been preserved in accordance with ethical standards.\u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflicts of Interest\u003c/h2\u003e \u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHammouda SB, Mabrouk S, Bellalah A, Maatouk M, Zakhama A, Njim L (2022) Large splenic epithelial cyst: A rare presentation. Int J Surg Case Rep 95:107201\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSenn AS, Bauer RC, Heigl A, Rosenberg R (2022) 23-year old man with a long history of abdominal pain, nausea and vomiting: Case report of a splenic cyst. Int J Surg Case Rep 93:106991\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacheras A, Misiakos EP, Liakakos T, Mpistarakis D, Fotiadis C, Karatzas G (2005) Non-parasitic splenic cysts: a report of three cases. World J Gastroenterol 11(43):6884\u0026ndash;6887\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadeghi A, Naderpour Z, Ebrahimpur M, Saffar H (2017) Non-parasitic Splenic Cyst. Middle East J Dig Dis 9(4):242\u0026ndash;243\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShukla RM, Mukhopadhyay M, Mandal KC, Mukhopadhyay B (2010) Giant congenital infected splenic cyst: An interesting case report and review of the literature. Indian J Surg 72(3):260\u0026ndash;262\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHansen MB, Moller AC (2004) Splenic cysts. Surg Laparosc Endosc Percutan Tech 14(6):316\u0026ndash;322\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRana AP, Kaur M, Singh P, Malhotra S, Kuka AS (2014) Splenic epidermoid cyst - a rare entity. J Clin Diagn Res 8(2):175\u0026ndash;176\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLopez JJ, Lodwick DL, Cooper JN, Hogan M, King D, Minneci PC (2017) Sclerotherapy for splenic cysts in children. J Surg Res 219:1\u0026ndash;4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTassopoulos A, Wein M, Segura A (2017) Traumatic rupture of a giant congenital splenic cyst presenting as peritonitis. Radiol Case Rep 12(2):401\u0026ndash;404\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrover S, Garg B, Sood N, Singh S (2016) Splenic Epidermoid Cyst in a Five-Year-Old Child. J Clin Diagn Res 10(7):ED07\u0026ndash;9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVuyyuru S, Kharbutli B (2017) Epidermoid cyst of the spleen, a case report. Int J Surg Case Rep 35:57\u0026ndash;59\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas M, Taiwo B (1994) Splenic epidermoid cysts presenting as an acute abdomen. Postgrad Med J 70(823):376\u0026ndash;377\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDa Costa C, Gaujoux S, Gouya H, Dousset B, Legmann P (2015) Epidermoid splenic cyst. Diagn Interv Imaging 96(4):417\u0026ndash;420\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorgenstern L (2002) Nonparasitic splenic cysts: pathogenesis, classification, and treatment. J Am Coll Surg 194(3):306\u0026ndash;314\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFowler RH (1953) Nonparasitic benign cystic tumors of the spleen. Int Abstr Surg 96(3):209\u0026ndash;227\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShabtaie SA, Hogan AR, Slidell MB (2016) Splenic Cysts Pediatr Ann 45(7):e251\u0026ndash;e256\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShirkhoda A, Freeman J, Armin AR, Cacciarelli AA, Morden R (1995) Imaging features of splenic epidermoid cyst with pathologic correlation. Abdom Imaging 20(5):449\u0026ndash;451\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGianom D, Wildisen A, Hotz T, Goti F, Decurtins M (2003) Open and laparoscopic treatment of nonparasitic splenic cysts. Dig Surg 20(1):74\u0026ndash;78\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Alsalama Hospital, Jeddah, Saudi Arabia","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"splenic cyst, epidermoid cyst, splenic rupture, splenectomy, conservative management","lastPublishedDoi":"10.21203/rs.3.rs-8808711/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8808711/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: splenic cysts are uncommon in pediatric patients and mostly asymptomatic and incidentally discovered but may present with abdominal discomfort. Large cyst may rupture after minor trauma leading to life-threatening hemorrhage. Splenic preserving measuring is the main goal of management for pediatrics, however life-saving splenectomy is crucial in critical conditions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e: We have reported a case of 15-years-old who experienced trivial abdominal trauma leading to hemoperitoneum due to rupture splenic cyst confirmed with contrast-enhanced CT abdomen and pelvis. After resuscitation and failure of conservative management, splenectomy was performed uneventually and patient was discharge in a stable condition. This case highlights the diagnostic and management challenges associated with splenic cyst rupture in an adolescent patient.\u003c/p\u003e","manuscriptTitle":"When Minor Trauma Leads to Major Surgery: Splenic Cyst Rupture Requiring Emergency Splenectomy After Failed Conservative Management in a 15-Year-Old Boy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 16:33:21","doi":"10.21203/rs.3.rs-8808711/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dc093323-e1ce-4073-9330-602ea85203b9","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":62466929,"name":"General Surgery"}],"tags":[],"updatedAt":"2026-04-24T10:38:29+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-10 16:33:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8808711","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8808711","identity":"rs-8808711","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}