Presentation
Abdominal pain and hypotension following a motor vehicle accident.
Patient Data
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Moderate ascites are noted in the peritoneal cavity as well as sentinel clot around the spleen. The shattered spleen and few foci of active arterial bleeding are seen as the source of hemoperitoneum.
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The first image shows free fluid and sentinel clot around the spleen (the blue star).
The other five images are three pairs of arterial (red circle) and corresponding portal phase (black arrow and circle) depicting active arterial bleeding. Notice the increasing in size and the density of extravasated contrast in the portal phase compared with the arterial phase, a key clue for the detection of active bleeding. The round focus of contrast collection in the mid spleen level in the arterial phase is dispersed in the portal phase and losses the round shape, which is against pseudoaneurysm. The dispersal and mixing of extravasated contrast lead to obscuration of it during the portal phase in the second pair. In the first pair, the focus of active bleeding in the arterial phase is not visible, the contrast in the portal phase of the first pair is the dispersed extravasated contrast from another more inferiorly located focus (the second pair).
Case Discussion
The patient underwent emergent laparotomy and splenectomy because of hemodynamic instability from hypovolemic shock. Active arterial bleeding of the shattered spleen confirmed during surgery. No other organ injury was found.