Abstract
Atraumatic spontaneous splenic rupture (ASR) is a rare, potentially fatal condition accounting for fewer than 0.5% of all splenic ruptures, with reported mortality of up to 20% when diagnosis is delayed. We report a 63‐year‐old male with decompensated chronic liver disease and portal hypertension who presented with acute epigastric pain, progressive abdominal distension, and absolute constipation without antecedent trauma. Abdominal ultrasonography identified splenomegaly with a 5 × 6 cm anechoic intraparenchymal collection with subcapsular and perisplenic extension and moderate hemoperitoneum. Noncontrast computed tomography confirmed parenchymal laceration classified as AAST Grade III/WSES Class II. Contrast‐enhanced CT was deferred because of concurrent renal impairment. The patient remained hemodynamically stable and was successfully managed with conservative nonoperative management. This case highlights the importance of suspecting ASR in patients with hepatic disease and congestive splenomegaly without trauma, the utility of prognostic scoring in guiding management, and the role of contrast‐enhanced ultrasound as a nephroprotective imaging alternative when iodinated contrast is contraindicated.