Presentation
Passed out at home after vomiting. Presented to the ER with extreme weakness.
Patient Data
Ruptured spleen with multiple foci of active bleeding; although the post-contrast scan was done during the early portal phase, it is safe to assume that much of the foci represent arterial bleeding. The relatively well-defined zone of rupture is suspicious for a hemorrhagic mass.
Copious amount of free intraperitoneal blood, with areas of clotting, notably anterior to the spleen (as is expected) and above and immediately to the right of the distal sigmoid colon.
Case Discussion
A girl with no known illness presented to the pediatric ER with extreme weakness, having passed out after vomiting. BP on admission 50/0 mmHg, HR 156/min, saturation 90% in room air.
Positive findings on physical examination: general weakness, marked central and lip paleness, borderline skin turgor, sunken eyes, pale sclerae, distended abdomen, diffuse abdominal sensitivity, more pronounced in upper abdomen. Further lab results yielded severe metabolic acidosis (pH 7.09), high blood sugar (390 mg/dL) and anemia. Improved after receiving insulin and 1 L of saline.
CT abdomen showed a ruptured spleen with active bleeding and a copious amount of intraperitoneal blood.
Improved further after receiving 2 units of whole blood.
The girl was promptly taken to the OR, where she underwent splenectomy. The shape of the large "crater" of hemorrhage suggested to the surgeon that a cystic lesion had ruptured but the pathology report made no mention of any lesion. Of note, serology for CMV came back negative, as did an extensive panel for clotting factor deficiencies.
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