Delayed splenic rupture presenting 8 days following blunt abdominal trauma due to a motor vehicle accident

Abstract

Introduction

Hemodynamic instability in previously stable trauma patients carries rather not a wide differential diagnosis. Delayed Splenic Rupture is certainly not on the top of the list.

Case presentation

We present a patient with delayed splenic rupture eight days after a blunt abdominal trauma caused by a motor vehicle accident. The patient's initial full-body trauma protocol CT scan was negative for internal injuries and rib fractures. He was discharged after 48 h of uneventful observation. Returning eight days with grade III subcapsular splenic hematoma; with negative history of strenuous activities or a second trauma.

A trial of non-operative management was opted for after stabilizing the patient. However, the patient's hemodynamic status deteriorated and he was operated on a couple of hours after presentation.

Discussion

Delayed splenic rupture remains a rare diagnosis with an open time window for presentation. While it is a rare entity, delayed splenic rupture increases the mortality rate in an otherwise non-mortal injury.

Conclusion

This case presents an important educational value in bringing forth such rare diagnoses in trauma patients and highlights the management transition from a non-operative approach to an operative one.

Highlights

• •Delayed splenic rupture is a rare outcome of blunt abdominal trauma.
• •Presentation is similar to that of splenic rupture.
• •Management is guided by the patient's hemodynamic status.

1. Introduction

Delayed splenic rupture (DSR) is a known but rare outcome of blunt abdominal trauma. First described as the “latent period” by Baudet in 1907 referring to the period between initial injury and hemorrhagic signs [1]. Earlier work defined delayed splenic injury as bleeding 48 h following injury, recent literature supports a more prolonged period that extends between days to years [1]. The etiology of DSR has been historically linked to parenchymal pseudoaneurysms, subcapsular hematomas, splenic pseudocysts, and to a lesser degree, rib fractures [1]. The significance of delayed splenic injury comes from its high mortality rate (5–15 %) compared to acute splenic injuries (1 %) [[1], [2], [3]]. DSR presents with a picture of hemorrhagic shock depending on the degree of injury. The gold standard for diagnosis is a CT scan with IV contrast [4].

Here, we report a patient presenting with splenic rupture eight days after blunt abdominal trauma after a negative trauma protocol whole body CT-scan and 48-hour observation period with no acute abdominal pain or hemodynamic instability. The case report adheres to SCARE criteria [5].

2. Case description

A 32-year-old male patient presented to the emergency department (ED) with level III trauma criteria after being hit by a car while walking, resulting in him getting drafted into the car's windshield, and falling head-first onto the floor. On presentation, the patient was complaining of head, neck, chest, upper abdominal, lower back, and left leg pain. He had full recollection of the event with no history of loss of consciousness, nausea, or vomiting. His medical, surgical, and drug history were positive for discopathy but otherwise insignificant. On examination, the patient had a GCS of 15/15 and was hemodynamically stable, physical exam showed epigastric tenderness with an otherwise soft lax abdomen.

A trauma protocol full-body CT scan with IV contrast administration. In which the spleen was interpreted as normal in size and enhancement pattern on both pre-contrast and post-contrast acquisition. (Fig. 1) The patient was admitted to the surgical ward and was observed for 48 h with no reported complaints or events. Thus, he was discharged home to return to the general surgery clinic after 5 days on analgesia and muscle relaxants.

Fig. 1.

(A) Axial nonenhanced CT image shows normal splenic outlines with (B) Axial enhanced CT image (portal phase) shows normal splenic enhancement pattern.

On the morning of the 8th day following the accident. The patient visited the clinic, only complaining of neck and low back pain. He was started on gabapentin and advised to continue bed rest.

As the patient returned home from the visit, he started complaining of mild vague generalized abdominal pain, initially scoring 1–2/10 in severity, steadily increasing to a score of 10/10 and becoming more localized to the upper abdomen with radiation to the left shoulder.

2.1. Diagnostic assessment

An ultrasound was done at an outside facility due to the pain. It showed a moderate amount of fluid in the abdomen and a subcapsular hematoma causing compression over the spleen (Fig. 2). Thus, the patient was urgently transferred back to our care.

Fig. 2.

(A + B) longitudinal abdominal ultrasound images showing an elliptical subcapsular hematoma causing mass effect over the spleen.

On presentation, the patient was conscious, alert, and oriented (Glasgow coma scale: 15/15). However, he was sweaty, pale, and unable to lay supine. He had a regular heart rate of 127 beats per minute, blood pressure of 127/75 mmHg, and a respiratory rate of 23 breaths per minute. Necessitating a level II emergency response activation. On examination, the abdomen was tense with severe epigastric and left upper quadrant superficial and deep tenderness, with guarding at the left upper abdominal quadrant, with negative Gray Turner and Cullen's signs.

Laboratorical exams showed a hemoglobin level of 9.4 g per deciliter (g/dl) (HCT: 29 %), a drop from 14.3 g/dl (HCT: 44 %) on the initial admission. After stabilization, the patient was sent for an urgent complimentary abdominal CT scan with IV contrast administration which on both pre-contrast and post-contrast acquisition showed a large subcapsular hematoma involving >50 % of the surface area of the spleen (Fig. 3) with a moderate amount of free fluid in the abdomen denoting partial rupture classified as grade III injury according to American Association for the Surgery of Trauma (AAST) splenic injury scale.

Fig. 3.

(A) Axial nonenhanced CT image shows intrinsically hyperdense splenic subcapsular hematoma (star) compressing the splenic parenchyma, also free fluid in the peri-hepatic region (B) Axial enhanced CT image (portal phase) better delineates the subscapular hematoma (C) Coronal enhanced CT image (portal phase) shows the extend of subcapsular hematoma in craniocaudal dimension.

2.2. Therapeutic intervention

The patient was admitted to the ICU for close observation and planned for endovascular intervention. A few hours after the admission, the patient's hemoglobin level dropped to 8.4 g/dl (HCT: 28 %) and his heart rate increased to 135; he was transfused with two units of packed RBCs and two units of Fresh Frozen Plasma, restabilizing the patient. However, his heart rate increased to 150 s within 4 h with increasing levels of pain uncontrolled with opioids, his hemoglobin level drawn at that time was 7.6 g/dl (HCT: 24 %).

The patient was urgently transferred to the theatre for an urgent splenectomy. Upon exploration of the abdomen, large clots and free blood were found in the abdominal cavity; as the hematoma has ruptured. The spleen was found to be shattered into two halves. Suction of the clots and blood was done, followed by a splenectomy.

Postoperatively, the patient had a smooth course with a one-day stay in the ICU and four days stay in the open surgical ward. The patient remained hemodynamically stable in both wards with decreasing serosanguinous drain output and stable hemoglobin levels. The patient was discharged on the fifth postoperative day on Amoxicillin & Clavulanic acid with a booked appointment for post-splenectomy vaccinations. (Table 1, provides the timeline of the events).

Table 1.

Timeline of the patient's events.

Date (DD/MM/YYYY)	Event
14/01/2023	Initial trauma
16/01/2023	First discharge
23/01/2023	Second admission
24/01/2023	Operation day
29/01/2023	Second discharge
04/02/2023	First clinic visit
13/02/2023	ER visit
05/03/2023	Latest clinic visit

3. Follow-up and outcomes

The patient had no complaints on the initial follow-up visit one week after discharge. However, he returned to the emergency department complaining of dyspnea two weeks after discharge. He was found to have a left-sided pleural effusion (Fig. 4 A); which improved with conservative management two weeks later. (Fig. 4 B).

Fig. 4.

(A) Obliterated left costophrenic angle; pleural effusion. (B) Pleural effusion resolved the angle is no longer obliterated.

4. Discussion

Spleen injuries were traditionally managed surgically, however, with a more recent focus on salvaging the spleen. There has been a shift towards non-operative management (NOM). While the absolute indication of laparotomy remains hemodynamic instability and shock [6]. A trial for non-operative management in patients meeting the criteria below are indicated [[7], [8], [9]]: hemodynamic stability or readily stabilizable; lack of rebound and guarding; blood transfusions ≤4 units; no lack of consciousness; age < 55 years; documented splenic injury with imaging.

Our patient initially met the criteria above and was managed conservatively, during his management, the patient's hemodynamic status deteriorated and became unstabilizable without surgical intervention. Thus, laparotomy was indicated.

While DSR had been reported in the literature in patients post motor vehicle accidents (MVA). Two patients reported in the literature presented with multiple injuries including multiple rib fractures rather than soft tissue trauma, which was initially seen in our patient [10,11]. Moreover, both patients presented within 5 days and within the same hospital admission. Our patient had no rib fractures on both scans and showed no deterioration up until the described presentation. While the two patients reported above were in-patient during the event, signifying instability to be discharged earlier; unlike our patient.

DSR can present post-soft tissue trauma to the abdomen, initial scans are not usually negative [12]. As seen with a 37-year-old female patient who presented with a grade III splenic injury that progressed to a ruptured spleen [12].

5. Conclusion

This case highlights the rare presentation of DSR in soft-tissue trauma patients; with no rib fractures, and no history of strenuous exercise and activities or accidents in between the two scans. Our patient presented as a surgical abdomen after being on non-steroidal anti-inflammatory agents, thus a perforated peptic ulcer was high on our differential. This case served as a reminder for a broad differential. It also focused on the transition in management between NOM to operative management as the patient's hemodynamic status changed.

Ethical approval

The study was exempted from ethical review as issued by the IRB of Ibn Sina Specialized Hospital on May 11th, 2023. As it involves a brief summary of a deidentified patient’s information with accidental identification causing no harm to the patient’s reputation, employment, financial status, or legal standing. And an informed written consent was obtained.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

Bayan Alqtishat: concept, consent, literature review, drafting of the initial and final manuscript, approval of the final manuscript. Ahmad Hodali: concept, consent, drafting of the final manuscript, and approval of the final manuscript. Tawfiq Abukeshek: Drafting of the final manuscript and approval of the final manuscript. Tawfeeq Al-Shobaki: Concept and approval of the final manuscript.

Guarantor

Tawfeeq Al-Shobaki

Ahmad Hodali

Bayan Alqtishat

Patient perspective

Our patient was surprised by his sudden deterioration and emergent operation. At a follow-up visit one month after the operation, the patient was very grateful for his treatment, education, and continued medical attention.

Consent

Written informed consent was obtained from the parents for the publication of this case report and accompanying images.

Ethical statement

Written informed consent was obtained from the patient. The study was exempted from ethical review as issued by the IRB on May 11th, 2023.

Declaration of competing interest

The authors declare no competing interest.

Data availability

The original contributions presented in the study are included in the article. Further inquiries can be directed to the corresponding author.