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 Abstract
Splenic
injury is one of the commonest emergency
presentations of visceral injuries in
blunt abdominal trauma. Splenectomy was
the only treatment option for a long
time resulting in complications of
removal of the spleen like overwhelming
post splenectomy sepsis. With time a
widespread consensus has developed among
trauma surgeons to conserve the spleen
keeping in view the various
complications associated with its
removal.
Post traumatic pseudoaneurysm of
intraparenchymal splenic artery as a
possible mechanism of delayed rupture of
the spleen resulting in recurrent
emergency presentation, has been
demonstrated in the present report. It
also highlights the need for follow up
in patients treated conservatively and
proposes color Doppler ultrasonography
as a simple, reliable and inexpensive
modality for evaluation of all
complications of conservative management
of splenic trauma.
Introduction
The
incidence of splenic injury has
increased in recent years paralleling an
increase in road traffic accidents. The
current trend is towards conservative
management owing to a better
understanding of post-splenectomy
complications like sepsis. Non-operative
management was pioneered in pediatric
patients but has gained wide acceptance
in adults also. The mode and frequency
of post splenic injury monitoring is
still a gray area(1). Delayed
complications such as splenic abscesses
and pseudoaneurysm of the splenic artery
and its branches, and rupture of spleen
are rare but serious complications of
conservative management of splenic
injury(2).
The following case highlights a possible
mechanism of delayed rupture of spleen
and stresses the importance of adequate
and regular follow up in patients
managed conservatively after splenic
trauma. Color Doppler sonography is a
simple, reliable, non-ionizing and
inexpensive modality for repetitive
examination to rule out the presence of
such complications.
Case
Summary
A fifty five year old male patient
presented to the emergency section of
our hospital following a heavy vehicular
collision during a road traffic
accident.
Clinical examination revealed stable vital signs.
There was a contusion mark over the
lower left chest wall. There were no
apparent associated injuries. Abdominal
examination revealed mild tenderness
over the left upper abdomen with normal
bowel sounds. Hematological parameters
were normal with a hemoglobin level of
13 gm% and P.C.V.of 40%.
Chest x-ray was normal. Abdominal
sonography showed a splenic laceration
of about 3 cm near the lower pole of the
spleen surrounded by intraparenchymal
hematoma with minimal perisplenic fluid.
Hepatorenal pouch and flanks showed no
free fluid. No other visceral organ
injury was seen. Contrast enhanced CT
Scan of abdomen and pelvis corroborated
these findings. Conservative management
of the splenic injury was done. Serial
sonography done on day two and four
revealed resolution of haemoperitonium.
Splenic injury also showed signs of
regression.
The patient was discharged on seventh
post admission day in good health.
Sonography done prior to discharge
showed complete resolution of the
hemoperitoneum and marked resolution of
splenic hematoma. The laceration was
also comparatively smaller. Contrast
enhanced CT Scan of the abdomen and the
pelvis confirmed the sonographic
findings.
Exactly two weeks after discharge, the
patient again presented to the emergency
department in a state of shock with a
blood pressure of 80/50mm Hg and pulse
rate of 100bpm. He was pale and had
hemoglobin of 8.6 gm% with a PCV of 25%.
After resuscitation, ultrasonography
revealed a well-defined anechoic cystic
lesion of 2 x 2.1cm at the lower pole of
spleen (Fig.1) and intraperitoneal fluid
collection with internal echoes (haemoperitonium).
On color Doppler ultrasonography
pulsatile flow was seen in the cystic
lesion
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Figure 1 . Gray scale image
of the spleen showing a
hypoechoic lesion (2x2.1 cm
) at the lower pole (arrow)
with surrounding fluid
collection with internal
echoes (heamoperitonium) . |
with a feeding vessel probably being a
branch of the splenic artery (Fig.2&3).
The patient was posted for emergency
laparotomy and splenectomy was done. Per
operative findings were in accordance
with that of sonography. About 1200 ml
of hemorrhagic fluid was found in the
peritoneal cavity. The patient recovered
uneventfully and was discharged after
eight days post-splenectomy.
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Figure 2 . Color Doppler
image of the spleer showing
a branch of splenic artery
communicating with
hypoechoic lesion . |
|
Figure 3 . Color Doppler
image and Spectral analysis
of the lesion showing
pulsatile arterial flow
. |
Discussion
Conservative management or conservation
of the spleen is a widely accepted
treatment modality for the patient with
splenic injuries. This has been
emphasized further due to the
recognition of post splenectomy
complications(3,4). Complications of
conservative management of splenic
injury, though rare, are ground
realities, which cannot be ignored. The
most serious among these is the delayed
rupture of the spleen. In 15-30% of
patients, a two stage splenic rupture
may be expected within two weeks (5).
Several hypotheses exist as
to the etiology of delayed rupture
including expanding subcapsular
hematomas and intra-parenchymal
hematomas(2,6). Expanding pseudoaneurysm
is an important cause of delayed rupture
of the spleen(7). The pulsatile flow in
the pseudoaneurysm is responsible for
its expansion and subsequent rupture of
spleen. Rupture of pseudoaneurysm most
commonly occurs shortly after trauma.
However, delayed ruptures after about
three weeks of conservative treatment
have been reported(6). Our patient
presented with delayed rupture of the
spleen and hemoperitoneum, after three
weeks of abdominal trauma. In our case
the pseudoaneurysm was not identified or
had not formed at the initial discharge
of the patient. Goletti et al(8)
described a similar case, however their
patient underwent splenectomy before
rupture of the spleen. The possibility
of delayed formation of pseudoaneurysm,
which may subsequently rupture with
catastrophic consequences further
emphasizes the need for regular color
Doppler sonographic evaluation in
patients managed conservatively after
splenic trauma.
Wider studies need to
be undertaken to evolve a protocol for
the mode as well as frequency of follow
up after splenic injury. Ruptured
pseudoaneurysm is an important cause of
delayed rupture of spleen. Paya et
al(9), reported the occurrence of
pseudoaneurysm after three months of
spleen salvaging surgery and recommended
monthly follow up for a period of six
months. Sequential USG with color
Doppler, CECT or MRI can detect such
lesions early and help in non-surgical
treatment like transcatheter
embolization and splenic salvage
surgeries, thus avoiding complications
of splenic conservation.
MRI is expensive and is not easily available in developing
countries. CT scan is also expensive
and involves ionizing radiations.
USG with color Doppler has definite
advantages as it is simple, easily
available, cost effective, patient
friendly and avoids ionizing
radiations(8). It can also be
repeated as and when required.
We support the view of authors(9), where patients of splenic
trauma who are managed
conservatively, be serially followed
with color Doppler ultrasonography
for about six months to avoid
complications like catastrophic
abdominal bleeds due to delayed
rupture of spleen.
References
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Case Report # 5
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