Delayed splenic rupture

Case contributed by RMH Core Conditions

Presentation

MVA vs pole

Patient Data

Age: 46
Gender: Male
CT

The liver contains no focal lesions. The portal and hepatic veins are opacified. The spleen is enlarged and measures 15.5 cm in maximum superoinferior span. It has a heterogeneous enhancement pattern which probably represents a perfusion artefact due to the splenic enlargement. No perisplenic fluid collection.

The gall bladder, pancreas, adrenal glands are normal. There are small cortical cysts in the kidneys. The aorta is normal. No para-aortic or pelvic lymphadenopathy. No free intraperitoneal fluid or gas.

There are displaced fractures of the right superior and inferior pubic rami and a comminuted intra-articular fracture of the right sacral ala involving the right sacroiliac joint. There is stranding in the soft tissues surrounding the right pubic ramus fractures there is thickening of the surrounding muscles as well as fat stranding at the right inferolateral margin of the bladder. No large intrapelvic collection. No displaced thoracolumbar spine fracture. There is an intramedullary nailin situ within the proximal left femur.

Conclusion

  1. Splenic enlargement with heterogeneous post-contrast enhancement the spleen, probably due to the splenic enlargement. No perisplenic fluid collection. No other upper abdominal traumatic injury.
  2. Pelvic fracture with swelling of the soft tissues around the pubic rami fracturesand perivesical fat stranding but no large intrapelvic fluid collection.

 

Six days later, in rehab, the patient developed epigastric pain with Hb drop. 

CT

The spleen has markedly increased in size and has become heterogeneous and demonstrates an irregular contour. The enhancing splenic parenchyma appears to be medial, with a large amount of heterogeneous subcapsular haematoma that is mainly lateral, with fluid-fluid levels. Extensive intra-abdominal and pelvic free fluid/blood with clot.

The liver, adrenal glands and pancreas appear normal. No cholelithiasis. Likely incidental small cysts within the kidneys. Flattened and volume depleted inferior vena cava. Mildly displaced and comminuted inferior and superior pubic ramus fracture and minimally displaced right sacral alar fracture, similar compared with previous scan. Intra medullary nail in the left proximal femur. IDC insitu. Small left-sided pleural effusion and associated with some dependent change and consolidation in the left lung base has developed.

Conclusion

Large subcapsular and intraperitoneal splenic hemorrhage with evidence of hypovolemia. 

DSA (angiography)

Coeliac axis and splenic artery angiography performed. No active bleeding seen. Main splenic artery embolised to occlusion with fibred microcoils via a microcatheter.

Case Discussion

Delayed splenic rupture occurs in 1-5% of patients and occurs between 4-8 days after injury. It has a significantly higher mortality rate than acute splenic injuries. 

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Case information

rID: 28571
Case created: 31st Mar 2014
Last edited: 1st Oct 2016
Inclusion in quiz mode: Included

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