INTRODUCTION Pain referred to in the left shoulder along with left upper quadrant hyperaesthesia after splenic rupture is a well-recognized physical sign, and was originally described by Hans Kehr (1862–1916) in the late 19th century. 1 We describe a previously unreported case of Kehr’s sign secondary to spontaneous rupture of the left inferior phrenic artery. CASE REPORT A 43-year-old woman was admitted as a surgical emergency patient with sudden onset left upper quadrant abdominal pain radiating to the left shoulder, which was exacerbated by cough- ing. On initial clinical examination the patient appeared well. She was haemodynamically stable with left upper quadrant abdominal pain but no signs of peritonitis. At this stage, her haemoglobin was 12.1 g/dL and her white cell count was 13.6; coagulation studies were normal. Erect chest and abdominal radiographs were unremark- able. An abdominal ultrasound scan demonstrated the presence of upper abdominal free fluid, and the spleen appeared enlarged and was surrounded by a mixed echogenic collection measuring approxi- mately 10 cm in diameter. An initial diagnosis of spontaneous splenic rupture was made. She was managed conservatively with regular observation. The following morning, the patient had deteri- orated with increasing abdominal pain, tachycardia and hypotension. Her haemoglobin was now 8.6 g/dL, so a transfusion was organized and an emergency laparotomy performed. Upon opening the peritoneal cavity, a small amount of fresh blood was seen anterior to the lesser curve of the stomach. The spleen appeared congested and there was a haematoma present in the transverse mesocolon and lesser sac. Upon re-inspection, the spleen had become displaced by a significant retroperitoneal haematoma, and it was thought that the patient had ruptured a splenic artery aneurysm (Fig. 1). The splenic artery was mobilized but it became immediately apparent that this was not the case. As the posterior wall of the lesser sac was incised there was 1.5 L of haematoma tracking behind the left triangular ligament. The left triangular ligament was mobilized and the haematoma was evacuated. A rupture of the left inferior phrenic artery was discovered on the inferior surface of the diaphragm and was under-run. The patient made an uneventful recovery and was discharged 4 days later. DISCUSSION Few cases describing bleeding from the phrenic arteries have been documented. The phrenic arteries are vessels of complex anatomical arrangement characterized by their variable origin – from the aorta, coeliac trunk or renal arteries – and multiplicity of branches. 2,3 In a search of the literature, two articles were found which describe injury to these arteries by laceration: (i) following percu- taneous needle lung biopsy presenting as a haemoperitoneum; 3 and (ii) as a complication of repairing pectus excavatum, 4 which presented as a haemothorax. Other rare cases of haemoperi- toneum involving the phrenic arteries have been documented in which the underlying aetiology was attributed to aneurysmal dilatation of the vessels. 5,6 We describe a unique case of spontaneous left inferior phrenic artery rupture of unknown aetiology associated with Kehr’s sign, which highlights that such rupture can occur in the absence of vessel disease or trauma. Spontaneous visceral artery rupture is an important, albeit uncommon clinical event that usually occurs in diseased vessels. Most articles in the literature describe aneurysmal dilatation as the most frequent underlying pathology involving visceral arteries, but equally emphasize the rarity of the finding; one such article defining the prevalence as 0.2% of the general population. 3–7 The splenic artery is reported to be the visceral artery most ANZ J. Surg. 2002; 72: 913–914 CASE REPORT KEHR’S SIGN – A RARE CAUSE: SPONTANEOUS PHRENIC ARTERY RUPTURE CHRISTOPHER D. SUTTON, LESLIE-JAYNE MARSHALL, STEVE A. WHITE, DAVID P. BERRY AND ASHLEY R. DENNISON Department of Surgery, Leicester General Hospital, Leicester, United Kingdom Key words: abdominal apoplexy, acute abdomen, diaphragm, haemorrhage, phrenic. C. D. Sutton FRCS; L. J. Marshall MB, ChB; S. A. White MD, FRCS; D. P. Berry MD, FRCS; A. R. Dennison MD, FRCS. Correspondence: Mr C. D. Sutton, Department of Surgery, Leicester General Hospital, Leicester, LE5 4PW, United Kingdom. Email: chrisdsutton@hotmail.com Accepted for publication 25 May 2001. Fig. 1. Perisplenic subdiaphragmatic haematoma caused by rupture of the inferior phrenic artery.