American Journal of Emergency Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Hemoperitoneum after blunt abdominal trauma 27 years after splenectomy: better think twice Abstract Traumatic splenic tissue injury in patients having previously undergone splenectomy has been very rarely reported. However, bleeding from splenic tissue (splenosis or accessory spleen) is should be added to the differential diagnosis of traumatic hemoperitoneum in patients having undergone previous splenectomy. We present a case of traumatic splenic tissue rupture occurring 27 years after a splenectomy was carried out for trauma. Emergency physicians should be aware of the possible presence of splenosis nodules or accessory spleens that can lead to hemoperitoneum and exsanguination from splenic bleeding, in previously splenectomized patients. Abdominal injury is present in 7% to 10% of all trauma patients admitted to hospital [1]. Hemoperitoneum is identified in approximately 40% of patients with blunt abdominal trauma [2,3], and splenic injury is the most frequently reported cause of intraabdominal bleeding [1,2]. The normally situated spleen is not the only potential source of hemoperitoneum of splenic origin: abdominal splenosis and accessory spleens may be alternative sources of bleeding [4–10]. Abdominal splenosis describes the presence of ectopic intraabdominal splenic tissue due to autotransplantation. Its prevalence may be as high as 66% in patients having undergone splenectomy for blunt abdominal trauma [11,12]. Moreover, accessory spleens are found in 10% to 30% of the general population [13–16]. We report here the case of a 47-year-old male patient, who was involved in a road traffic accident: while riding a motorcycle at approximately 30 km/h, he was struck by another motorcycle and had head, thoracic, and abdominal trauma. On arrival at our emergency department, his initial complaints were limited to pain in the left lower thorax and in the right knee. His medical history included a blunt traumatic abdominal injury sustained 27 years earlier also in a motorcycle accident, resulting in a grade 4 splenic fracture for which he had undergone total splenectomy. On physical examination, his blood pressure was 113/82 mm Hg; heart rate, 92 per minute; oxygen saturation, 94% on room air; and Glasgow Coma Scale, 15. The thoracic wall was tender to palpation over the left lowermost ribs. Breath sounds were symmetric and clear to auscultation. The abdomen was tender in the left upper quadrant, without any peritoneal irritation; clinical examination of the spine did not elicit pain and did not demonstrate bruising or deformity. Neurologic examination showed no deficit. The right knee was tender, with pain elicited by patellar palpation. Initial laboratory results showed a hemoglobin level of 155 g/L, a hematocrit of 44%, and normal coagulation profile. A contrast-enhanced
abdominal computed tomography (CT) revealed retroperitoneal and intraperitoneal hemorrhage in the left upper quadrant of the abdomen, with active bleeding (Figure). In addition, left ribs 6 to 9 were fractured. Plain films of the right knee demonstrated a transverse fracture of the patella. We held a splenotic nodule as the only possible origin of the intraperitoneal hemorrhage. The intraabdominal bleeding was managed conservatively. The hemoglobin level decreased to 132 g/L (hematocrit 40%) 12 hours after admission, remaining stable subsequently. The patellar fracture was also managed conservatively. A pulmonary embolism ensued on the second day, confirmed by repeat contrast-enhanced CT. This imagery also demonstrated that the volume of intraabdominal fluid was unchanged. Thus, the pulmonary embolism was managed initially by insertion of a vena cava filter and subsequently by oral anticoagulation. The patient was discharged on the seventh day. The classical clinical presentation of traumatic splenic injury is left upper quadrant pain and tenderness, with referred pain over the left shoulder (Kehr sign) [17]. Our patient complained only of lower left thoracic pain, with no spontaneous abdominal or shoulder pain. Traumatic splenic tissue rupture in patients having undergone previous splenectomy after trauma has been very rarely reported in the literature. We were only able to find four reported cases of traumatic rupture of splenosis nodules in adults in the last 30 years [4–6], one of which was caused by a minor trauma, namely, coughing [7]. An additional case was reported in a 9-year-old child [8]. Furthermore, cases of hemoperitoneum due to traumatic or atraumatic rupture of an accessory spleen have been reported [9,10,18–20]. The distinction between these 2 possible sources of bleeding—splenosis and accessory spleens—is not always obvious. The abdominal CT scan performed on admission in our patient showed no other evident splenotic nodules, and the vessel feeding the bleeding lesion was an artery originating from the celiac trunk. However, based on pathologic reports of the splenectomy carried out in 1987, the splenic capsule was disrupted, and no accessory spleen was found on intraoperative examination of the entire abdominal cavity. Furthermore, the splenic vessels, which are the usual feeders of accessory spleens, were ligated. Although variants of vascularization and location of accessory spleens exist [14], its persistence was unlikely in our case. All this indirect evidence supports a splenotic origin as the source of the hemorrhage. Postsplenectomy patients may still be at risk for hemoperitoneum due to bleeding splenic tissue after blunt abdominal trauma. In particular, patients who had capsular disruption of the spleen are at high risk for splenosis. Splenosis or an accessory spleen should be included in the list of potential bleeding causes in these patients, especially if their clinical presentation suggests a splenic injury.
http://dx.doi.org/10.1016/j.ajem.2015.12.032 0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Tagliabue L, et al, Hemoperitoneum after blunt abdominal trauma 27 years after splenectomy: better think twice, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2015.12.032
2
L. Tagliabue et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Figure. Arrow shows the bleeding splenotic nodule.
Luca Tagliabue MD Emergency Department, CHUV–Lausanne University Hospital Lausanne, Switzerland Corresponding author. CHUV, Service des Urgences, rue du Bugnon 46 1011 Lausanne, Switzerland E-mail address: [email protected] David Rotzinger MD Department of Radiology, CHUV–Lausanne University Hospital Lausanne, Switzerland Olivier Hugli MD, MPH Emergency Department, CHUV–Lausanne University Hospital Lausanne, Switzerland http://dx.doi.org/10.1016/j.ajem.2015.12.032 References [1] Costa G, Tierno SM, Tomassini F, et al. The epidemiology and clinical evaluation of abdominal trauma. An analysis of multidisciplinary trauma registry. Ann Ital Chir 2010 Mar-Apr;81(2):95–102. [2] Gamanagatti S, Rangarajan K, Kuma A, Jineesh. Blunt abdominal trauma: imaging and intervention. Curr Probl Diagn Radiol 2015 Jul-Aug;44(4):321–36. [3] Charbit J, Mahul M, Roustan JP, Latry P, Millet I, Taourel P, et al. Hemoperitoneum semiquantitative analysis on admission of blunt trauma patients improves the prediction of massive transfusion. Am J Emerg Med 2013 Jan;31(1):130–6. [4] Delamarre J, Capron JP, Drouard F, Joly JP, Deschepper B, Carton S. Splenosis: ultrasound and CT findings in a case complicated by an intraperitoneal implant traumatic hematoma. Gastrointest Radiol 1988;13(3):275–8.
[5] Leker JG, Yonehiro LR, Davis WC. Traumatic rupture of splenosis. J Trauma 1985 Jun; 25(6):560–2. [6] Kim M, Schroeppel T, Magnotti L, Fischer P, Croce M, Fabian T. Nonoperative management of traumatic rupture of splenosis. Inj Extra 2008;39(4):147–9. [7] Redan JA, Halili FR, Villarosa JS. Recurrent ruptured spleen. JSLS 2013 Oct-Dec;17(4): 651–3. [8] Carreira M, Conde R, Miranda C, Cardeiras R, Gurriarán MJ. Post-traumatic hemoperitoneum: a rare complication of peritoneal splenosis. [article in Spanish] Rev Clin Esp 1991 Sep;189(4):175–7. [9] Depypere L, Goethals M, Janssen A, Olivier F. Traumatic rupture of splenic tissue 13 years after splenectomy. A case report. Acta Chir Belg 2009 Jul-Aug;109(4): 523–6. [10] Hardiment K, Gunn J. Atraumatic rupture os a splenunculus 30 years following splenectomy for idiopathic thrombocytopenic purpura: a case report. IJS 2005:7(2). [11] Lüdtke FE, Mack SC, Schuff-Werner P, Voth E. Splenic function after splenectomy for trauma. Role of autotransplantation and splenosis. Acta Chir Scand 1989 Oct; 155(10):533–9. [12] Gunesa I, Yilmazlar T, Sarikayaa I, Akbunara T, Irgil C. Scintigraphic detection of splenosis: superiority of tomographic selective spleen scintigraphy. Clin Radiol 1994 Feb;49(2):115–7. [13] Mortelé KJ, Mortelé B, Silverman SG. CT features of the accessory spleen. Am J Roentgenol 2004;183(6):1653–7. [14] Gayer G, Zissin R, Apter S, Atara E, Portnoy O, Itzchak Y. Pictorial review CT findings in congenital anomalies of the spleen. J Radiol 2001;74:767–72. [15] Freeman JL, Jafri SZH, Roberts JL, Mezwa DG, Shirkhoda A. CT of congenital and acquired abnormalities of the spleen. Radiographics 1993;13:597–610. [16] Dodds WJ, Taylor AJ, Erickson SJ, Stewart ET, Lawson TL. Radiologic imaging of splenic anomalies. Am J Roentgenol 1990;155(4):805–10. [17] Lowenfels AB. Kehr's sign—a neglected aid in rupture of the spleen. N Engl J Med 1966 May 5;274(18):1019. [18] Katz DS, Moshiri M, Smith G, Meiner EM, Fruauff AA. Spontaneous haemorrhage of abdominal splenosis. J Comput Assist Tomogr 1998 Sept-Oct;22(5):725–7. [19] Feferman I, Cramer J. Splenosis: an unusual cause of intraabdominal hemorrhage. J Emerg Med 1991;9(4):239–40. [20] Lanigan DJ. Spontaneous rupture of a splenotic nodule. Postgrad Med J 1990 Nov; 66(781):971–3.
Please cite this article as: Tagliabue L, et al, Hemoperitoneum after blunt abdominal trauma 27 years after splenectomy: better think twice, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2015.12.032
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Hemoperitoneum after blunt abdominal trauma 27 years after splenectomy: better think twice Abstract Traumatic splenic tissue injury in patients having previously undergone splenectomy has been very rarely reported. However, bleeding from splenic tissue (splenosis or accessory spleen) is should be added to the differential diagnosis of traumatic hemoperitoneum in patients having undergone previous splenectomy. We present a case of traumatic splenic tissue rupture occurring 27 years after a splenectomy was carried out for trauma. Emergency physicians should be aware of the possible presence of splenosis nodules or accessory spleens that can lead to hemoperitoneum and exsanguination from splenic bleeding, in previously splenectomized patients. Abdominal injury is present in 7% to 10% of all trauma patients admitted to hospital [1]. Hemoperitoneum is identified in approximately 40% of patients with blunt abdominal trauma [2,3], and splenic injury is the most frequently reported cause of intraabdominal bleeding [1,2]. The normally situated spleen is not the only potential source of hemoperitoneum of splenic origin: abdominal splenosis and accessory spleens may be alternative sources of bleeding [4–10]. Abdominal splenosis describes the presence of ectopic intraabdominal splenic tissue due to autotransplantation. Its prevalence may be as high as 66% in patients having undergone splenectomy for blunt abdominal trauma [11,12]. Moreover, accessory spleens are found in 10% to 30% of the general population [13–16]. We report here the case of a 47-year-old male patient, who was involved in a road traffic accident: while riding a motorcycle at approximately 30 km/h, he was struck by another motorcycle and had head, thoracic, and abdominal trauma. On arrival at our emergency department, his initial complaints were limited to pain in the left lower thorax and in the right knee. His medical history included a blunt traumatic abdominal injury sustained 27 years earlier also in a motorcycle accident, resulting in a grade 4 splenic fracture for which he had undergone total splenectomy. On physical examination, his blood pressure was 113/82 mm Hg; heart rate, 92 per minute; oxygen saturation, 94% on room air; and Glasgow Coma Scale, 15. The thoracic wall was tender to palpation over the left lowermost ribs. Breath sounds were symmetric and clear to auscultation. The abdomen was tender in the left upper quadrant, without any peritoneal irritation; clinical examination of the spine did not elicit pain and did not demonstrate bruising or deformity. Neurologic examination showed no deficit. The right knee was tender, with pain elicited by patellar palpation. Initial laboratory results showed a hemoglobin level of 155 g/L, a hematocrit of 44%, and normal coagulation profile. A contrast-enhanced
abdominal computed tomography (CT) revealed retroperitoneal and intraperitoneal hemorrhage in the left upper quadrant of the abdomen, with active bleeding (Figure). In addition, left ribs 6 to 9 were fractured. Plain films of the right knee demonstrated a transverse fracture of the patella. We held a splenotic nodule as the only possible origin of the intraperitoneal hemorrhage. The intraabdominal bleeding was managed conservatively. The hemoglobin level decreased to 132 g/L (hematocrit 40%) 12 hours after admission, remaining stable subsequently. The patellar fracture was also managed conservatively. A pulmonary embolism ensued on the second day, confirmed by repeat contrast-enhanced CT. This imagery also demonstrated that the volume of intraabdominal fluid was unchanged. Thus, the pulmonary embolism was managed initially by insertion of a vena cava filter and subsequently by oral anticoagulation. The patient was discharged on the seventh day. The classical clinical presentation of traumatic splenic injury is left upper quadrant pain and tenderness, with referred pain over the left shoulder (Kehr sign) [17]. Our patient complained only of lower left thoracic pain, with no spontaneous abdominal or shoulder pain. Traumatic splenic tissue rupture in patients having undergone previous splenectomy after trauma has been very rarely reported in the literature. We were only able to find four reported cases of traumatic rupture of splenosis nodules in adults in the last 30 years [4–6], one of which was caused by a minor trauma, namely, coughing [7]. An additional case was reported in a 9-year-old child [8]. Furthermore, cases of hemoperitoneum due to traumatic or atraumatic rupture of an accessory spleen have been reported [9,10,18–20]. The distinction between these 2 possible sources of bleeding—splenosis and accessory spleens—is not always obvious. The abdominal CT scan performed on admission in our patient showed no other evident splenotic nodules, and the vessel feeding the bleeding lesion was an artery originating from the celiac trunk. However, based on pathologic reports of the splenectomy carried out in 1987, the splenic capsule was disrupted, and no accessory spleen was found on intraoperative examination of the entire abdominal cavity. Furthermore, the splenic vessels, which are the usual feeders of accessory spleens, were ligated. Although variants of vascularization and location of accessory spleens exist [14], its persistence was unlikely in our case. All this indirect evidence supports a splenotic origin as the source of the hemorrhage. Postsplenectomy patients may still be at risk for hemoperitoneum due to bleeding splenic tissue after blunt abdominal trauma. In particular, patients who had capsular disruption of the spleen are at high risk for splenosis. Splenosis or an accessory spleen should be included in the list of potential bleeding causes in these patients, especially if their clinical presentation suggests a splenic injury.
http://dx.doi.org/10.1016/j.ajem.2015.12.032 0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Tagliabue L, et al, Hemoperitoneum after blunt abdominal trauma 27 years after splenectomy: better think twice, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2015.12.032
2
L. Tagliabue et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Figure. Arrow shows the bleeding splenotic nodule.
Luca Tagliabue MD Emergency Department, CHUV–Lausanne University Hospital Lausanne, Switzerland Corresponding author. CHUV, Service des Urgences, rue du Bugnon 46 1011 Lausanne, Switzerland E-mail address: [email protected] David Rotzinger MD Department of Radiology, CHUV–Lausanne University Hospital Lausanne, Switzerland Olivier Hugli MD, MPH Emergency Department, CHUV–Lausanne University Hospital Lausanne, Switzerland http://dx.doi.org/10.1016/j.ajem.2015.12.032 References [1] Costa G, Tierno SM, Tomassini F, et al. The epidemiology and clinical evaluation of abdominal trauma. An analysis of multidisciplinary trauma registry. Ann Ital Chir 2010 Mar-Apr;81(2):95–102. [2] Gamanagatti S, Rangarajan K, Kuma A, Jineesh. Blunt abdominal trauma: imaging and intervention. Curr Probl Diagn Radiol 2015 Jul-Aug;44(4):321–36. [3] Charbit J, Mahul M, Roustan JP, Latry P, Millet I, Taourel P, et al. Hemoperitoneum semiquantitative analysis on admission of blunt trauma patients improves the prediction of massive transfusion. Am J Emerg Med 2013 Jan;31(1):130–6. [4] Delamarre J, Capron JP, Drouard F, Joly JP, Deschepper B, Carton S. Splenosis: ultrasound and CT findings in a case complicated by an intraperitoneal implant traumatic hematoma. Gastrointest Radiol 1988;13(3):275–8.
[5] Leker JG, Yonehiro LR, Davis WC. Traumatic rupture of splenosis. J Trauma 1985 Jun; 25(6):560–2. [6] Kim M, Schroeppel T, Magnotti L, Fischer P, Croce M, Fabian T. Nonoperative management of traumatic rupture of splenosis. Inj Extra 2008;39(4):147–9. [7] Redan JA, Halili FR, Villarosa JS. Recurrent ruptured spleen. JSLS 2013 Oct-Dec;17(4): 651–3. [8] Carreira M, Conde R, Miranda C, Cardeiras R, Gurriarán MJ. Post-traumatic hemoperitoneum: a rare complication of peritoneal splenosis. [article in Spanish] Rev Clin Esp 1991 Sep;189(4):175–7. [9] Depypere L, Goethals M, Janssen A, Olivier F. Traumatic rupture of splenic tissue 13 years after splenectomy. A case report. Acta Chir Belg 2009 Jul-Aug;109(4): 523–6. [10] Hardiment K, Gunn J. Atraumatic rupture os a splenunculus 30 years following splenectomy for idiopathic thrombocytopenic purpura: a case report. IJS 2005:7(2). [11] Lüdtke FE, Mack SC, Schuff-Werner P, Voth E. Splenic function after splenectomy for trauma. Role of autotransplantation and splenosis. Acta Chir Scand 1989 Oct; 155(10):533–9. [12] Gunesa I, Yilmazlar T, Sarikayaa I, Akbunara T, Irgil C. Scintigraphic detection of splenosis: superiority of tomographic selective spleen scintigraphy. Clin Radiol 1994 Feb;49(2):115–7. [13] Mortelé KJ, Mortelé B, Silverman SG. CT features of the accessory spleen. Am J Roentgenol 2004;183(6):1653–7. [14] Gayer G, Zissin R, Apter S, Atara E, Portnoy O, Itzchak Y. Pictorial review CT findings in congenital anomalies of the spleen. J Radiol 2001;74:767–72. [15] Freeman JL, Jafri SZH, Roberts JL, Mezwa DG, Shirkhoda A. CT of congenital and acquired abnormalities of the spleen. Radiographics 1993;13:597–610. [16] Dodds WJ, Taylor AJ, Erickson SJ, Stewart ET, Lawson TL. Radiologic imaging of splenic anomalies. Am J Roentgenol 1990;155(4):805–10. [17] Lowenfels AB. Kehr's sign—a neglected aid in rupture of the spleen. N Engl J Med 1966 May 5;274(18):1019. [18] Katz DS, Moshiri M, Smith G, Meiner EM, Fruauff AA. Spontaneous haemorrhage of abdominal splenosis. J Comput Assist Tomogr 1998 Sept-Oct;22(5):725–7. [19] Feferman I, Cramer J. Splenosis: an unusual cause of intraabdominal hemorrhage. J Emerg Med 1991;9(4):239–40. [20] Lanigan DJ. Spontaneous rupture of a splenotic nodule. Postgrad Med J 1990 Nov; 66(781):971–3.
Please cite this article as: Tagliabue L, et al, Hemoperitoneum after blunt abdominal trauma 27 years after splenectomy: better think twice, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2015.12.032
