Case reports and case series’ were examined for relevance. Data was extracted from cases referenced in review papers only if the original paper was not available to us, and these were cross-referenced with case reports to prevent duplicate recording. Papers pertaining to the rupture of diseased spleens were excluded if the disease was correctly diagnosed prior to presentation at the emergency department. Cases of splenic rupture occurring immediately following any trauma (including trivial) were also excluded. Delayed splenic rupture cases were

excluded if they occurred greater Inhibitors,research,lifescience,medical than 48 hours after major trauma (because this phenomenon is well reported in the literature and textbooks), but were included if the inciting traumatic event was considered Inhibitors,research,lifescience,medical by the two authors to be of trivial severity. Although the degree of trauma is debatable, we elected to include cases likely caused by cough or vomiting because we felt that these aetiologic factors were also under-appreciated. Although delayed post-medical procedure rupture of the spleen is documented in the proceduralist (surgical and GI) literature, it is not documented in EM textbooks and we have elected to include Inhibitors,research,lifescience,medical these cases here. We limited our report to papers published since 1950. Although the diagnosis

and treatment of splenic rupture has changed Inhibitors,research,lifescience,medical considerably in recent years, we found no evidence to suggest that the underlying causes of rupture have changed during this time period. Because the primary purpose of our paper was to highlight

aetiology and not diagnosis or management, we elected to choose a somewhat broader time period than might have been appropriate for a study with a different purpose. The information extracted onto a spreadsheet included the splenic disease process if any, other evidence Inhibitors,research,lifescience,medical of splenic abnormality (anatomical or histological), and the nature of any associated trauma. Causative processes were grouped into clinically relevant categories. We did not attempt to document histological or pathological findings, or review diagnostic or treatment methods as these are recently reviewed in detail elsewhere [4,5]. Results No Medical Subject almost Headings or other keywords reliably identified the 396 papers reporting 607 cases of splenic rupture that met our inclusion criteria. Thus, we manually reviewed many abstracts and papers that ended up being excluded from this review (Figure ​(Figure1).1). Some case series referenced here report both cases meeting our inclusion criteria and others meeting our exclusion criteria; only those meeting the inclusion criteria are included. We attempted to obtain all of the original papers referenced here so that we could document the cases without relying on Brefeldin A mw secondary sources.