A rare mechanism of delayed splenic rupture following the nonoperative management of blunt splenic injury in a child

Abstract

BackgroundNonoperative management (NOM) has been established as the standard treatment for isolated blunt organ injury in hemodynamically stable pediatric patients. Although delayed splenic rupture or bleeding is a rare complication in NOM, it is an issue that many pediatric surgeons are greatly concerned about. We herein report a rare pediatric case concerning the mechanisms involved in delayed splenic rupture after NOM.Case presentationA 9-year-old boy with severe abdominal pain was transferred to our hospital. Twenty-one hours before the admission, he had been kicked in the region of his left lateral abdomen. Contrast-enhanced abdominal computed tomography revealed a severe intra-parenchymal hematoma and multiple lacerations of the spleen with a large amount of hemoperitoneum without active bleeding. His condition was diagnosed as a grade III injury on the AAST splenic injury scale. After fluid resuscitation, his vital signs became stable. The patient was treated with NOM in our intensive care unit. However, suddenly after defecation (72 h after the injury), he started complaining of severe abdominal pain and left shoulder pain. His blood pressure dropped to 70/35 mmHg, and he started to lose consciousness. Abdominal ultrasonography (US) revealed increased ascites. Fluid resuscitation and blood transfusion were performed. His symptoms and abdominal US findings suggested that splenic re-bleeding had caused delayed splenic rupture to occur. Emergency splenectomy was performed. The resected spleen was enlarged with a large parenchymal hematoma. The posterior-lateral side of the splenic capsule was ruptured.ConclusionsThe mechanism of delayed splenic rupture in our case was considered to be the result of a tear in the subcapsular hematoma caused by stretching the splenocolic ligament related to a bowel movement during defecation. Although delayed splenic rupture or bleeding is unpredictable, it is very important to understand the mechanisms and to educate the family of the children with splenic injuries of the warning signs of delayed rupture or bleeding.

Risks and Realities of Delayed Splenic Bleeding

“…Etiologies may include subcapsular hematoma, pseudoaneurysm formation, splenic pseudocyst formation, or abscess formation. 3 Regardless of the cause, patients with splenic injury can have massive bleeding for greater than 24 hours after the initial trauma in up to 10 per cent of NOM of BSI, 1 but more commonly seen between 2 and 8 per cent of cases. 4 Up to 90 per cent of DSB occurs within 10 days of the injury, 1 with the vast majority of DSB occurring within 14 days of initial injury.…”

Delayed splenic rupture 4 months following minor blunt abdominal trauma

“…Interestingly, Shinkai et al, reported a case of a subcapsular tear during defecation, due to splenocolic ligament stretching. [3] Cases of splenic injury after colonoscopy, most often caused by traction on the splenocolic ligament or excessive manipulation during the procedure have been reported in the literature [4] Similarly, sneezing, coughing or the distention of the stomach after eating a heavy meal in a combination of rising of intra-abdominal pressure have also been associated with DSR [5].…”

Atraumatic splenic rupture and infection-related glomerulonephritis in a patient with infected aortic aneurysm: A case report

“…It is our firm belief that the management of atraumatic splenic rupture is basically the same as that for traumatic cases. If the vital signs are stable, preserved management may be an option [2] . In hemodynamically stable cases, interventional radiology can also be considered for control of bleeding [14] .…”

“…Splenic rupture usually occurs secondary to blunt trauma, and its management is controversial. Non-operative management is recommended in hemodynamically stable patients but carries the risk of delayed splenic rupture [1] , [2] . In contrast, atraumatic splenic rupture is very rare and difficult to diagnose.…”