Active splenic bleeding
End-stage renal disease with recent change from peritoneal dialysis to haemodialysis due to abdominal pain and sepsis. Haemoglobin dropped.
CT Abdomen and pelvis
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The amount of free fluid in the peritoneal cavity is overall stable compared to the previous imaging, although there is now active haemorrhage on the lateral aspect of the spleen characterised by contrast extravasation within a subcapsular haematoma. The haemorrhage tracks down to the pelvis and mix with the ascites elevating its average attenuation. There is small volume fluid extending through a right lateral inferior abdominal wall hernia.
Multiple colonic diverticula. Bowel is otherwise unremarkable. No free gas.
The liver, pancreas, and adrenal glands are unremarkable. Multiple small calcified gallstones. Kidneys have reduced dimensions. No hydronephrosis.
There is no lymph node enlargement. No suspicious bone lesions are seen.
Small left side pleural effusion. Bilateral gynecomastia.
Ill-defined fat stranding and small subcutaneous haematoma in the anterior abdominal wall are probably related to previous catheter manipulations.
MACROSCOPIC DESCRIPTION: The specimen consists of a spleen weighing 116g. The medial surface of the spleen is ragged and has a pale area 50x40mm on the capsule. The remainder of the splenic capsule is intact and appears unremarkable. On sectioning, there is a defect adjacent to the pale area that extends into the spleen and parenchyma. However, no obvious lesion is identified within the spleen. The parenchyma is very soft and friable but there is no discrete lesion. Representative sections are taken from around the defect and pale area.
MICROSCOPIC DESCRIPTION: Sections show spleen which is focally disrupted and haemorrhagic. Extending from the hilum into the spleen there are large vessels and some fat, which may account for the macroscopic appearance of the pale area. There is no abscess identified.
DIAGNOSIS: Spleen: Features consistent with traumatic rupture. No evidence of infection.
This case illustrates active splenic bleeding with haemoperitoneum. Histopathology after surgery did not reveal any underlying cause such as amyloid or infection. The cause was assumed to be traumatic, although the exact mechanism was not clear (peritoneal catheter removal? trauma on the ward?).