Sequelae of splenectomy

Case contributed by Dr Yair Glick

Presentation

Fall off motorcycle.

Patient Data

Age: 25 years
Gender: Male

Multiple splenic lacerations, the largest 3 cm in length. Focus of active arterial bleeding 2.7 cm long (craniocaudal) on arterial phase (AAST IV) close to the center of the spleen. Large heterogeneous subcapsular hematoma. Sizable amount of intraperitoneal hemorrhage, with the large perisplenic loculation already appearing clotted.

After 1.5 years, shows up at the ER complaining of diffuse abdominal pain.

The stomach is markedly distended.
Loops of distal jejunum-proximal ileum distended up to diameter of 3.8 cm, with air-fluid levels and rapid gradual dilution of intraluminal contrast material.
The spleen has been removed; appears lacerated on previous study 1.5 years earlier (see study below). Splenules currently in its location, as well as several others embedded in the omentum (see annotated images below). Transition point to collapsed ileum in lower abdomen at midline.

In summary:
Radiographic picture of small bowel obstruction, most probably adhesive, likely resulting from the previous splenectomy.

 

The first image is a coronal reformation with the arrow pointing at the transition point between a dilated and a collapsed small bowel loop.

In the rest of the images, the arrows point to splenules.

Case Discussion

Fell off his motorcycle and sustained multiple injuries, the most severe was to his left abdomen. Hemoglobin 9 g/dL.

Excerpt from the exploratory laparotomy - splenectomy:
On entering the abdominal cavity - large amount of blood, many thrombi. 4 L of blood evacuated.
Large splenic hematoma, multiple splenic lacerations (AAST III), bleeding.
[...]
Distal omental hematoma.

1.5 years later presents with diffuse abdominal pain and leukocytosis.
CT abdomen reveals small bowel obstruction (SBO), most probably adhesive, as well as splenosis.

Excerpt from the exploratory laparotomy - SBO:
Mutiple adhesions of small bowel to the abdominal wall.
On arrival at the abdominal cavity, multiple adhesions between bowel loops.

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