Splenic Rupture Following Extracorporeal Shockwave Lithotripsy: A Case Requiring Emergency Splenectomy

Abstract

Patient: Male, 72-year-old

Final Diagnosis: Splenic rupture

Symptoms: Abdominal pain • nausea • anemia

Clinical Procedure: —

Specialty: Surgery

Objective:

Management of emergency care

Background:

Extracorporeal shockwave lithotripsy (ESWL) is a common procedure, and splenic rupture is a rare complication of ESWL. Depending on the stage of injury and patient’s condition, treatment options include non-operative management (NOM) and emergency splenectomy. Diagnosis is not difficult with symptoms such as deteriorating hemodynamic and hematologic indices, localized physical signs of peritoneal irritation in the left hypochondriac region, and confirmation provided by signs of free fluid (hemoperitoneum) seen on ultrasound or computed tomography (CT). Prompt diagnosis and treatment are essential for patient survival. If NOM is not feasible, emergency laparotomy with splenectomy is standard procedure.

Case Report:

A 72-year-old man with a medical history of arterial hypertension and cardiac arrhythmia was emergently admitted 1 day after undergoing ESWL for bilateral nephrolithiasis. He presented with abdominal pain, nausea, vomiting, and anemia. Urgent CT confirmed a splenic rupture, with intraperitoneal fluid. He underwent emergency splenectomy 24 h after ESWL. Complete splenic rupture (grade IV) was identified, accompanied by significant blood loss of 2000 mL. The postoperative course was uneventful, and he was discharged on postoperative day 7, with primary wound healing.

Conclusions:

Splenic injury following ESWL is a rare but serious complication. Our case underscores the importance of monitoring for splenic injury following ESWL. Management should be multidisciplinary, considering physiological, anatomical, and immunological aspects. While splenectomy is the standard treatment, NOM can be considered for hemodynamically stable patients to avoid complications following splenectomy. Recent treatment protocols have improved stone breakage and reduced tissue damage, suggesting long-term adverse effects can be minimized or eliminated.

Introduction

Extracorporeal shockwave lithotripsy (ESWL) is a relatively safe and commonly used procedure to treat moderately sized upper ureter stones with a high success rate [1].

The mechanisms underlying shock wave lithotripsy (SWL) for stone fragmentation involve the generation of shear stress and cavitation, which can potentially induce tissue and vascular damage, ultimately resulting in acute and significant renal injury [2].

Serious complications of this procedure occur in less than 1% of patients, with most of these complications involving the renal tissue and presenting as hematuria. However, injuries to extrarenal tissues can also occur, with potentially serious consequences, if not detected early. Splenic laceration is one of these rare complications that has been described previously in isolated case reports.

Our case, which involved a spleen rupture following ESWL requiring emergency splenectomy, will highlight the case details and review all similar cases documented in the literature.

Case Report

A 72-year-old man was admitted emergently in April 2023 with a diagnosis of hemoperitoneum and splenic rupture. His comorbidities included arterial hypertension and cardiac arrhythmia. He underwent ESWL for bilateral nephrolithiasis 1 day prior to admission. Upon arrival, the patient had abdominal pain, nausea, and vomiting.

The clinical physical examination revealed a visibly aged man, corresponding to the calendar, with a hypersthenic habitus and poor general condition. He was afebrile, alert, and responsive. The skin and visible mucous membranes were pale. The respiratory system showed symmetrical chest movements and a vesicular breathing pattern, without any wheezing. The cardiovascular system showed a blood pressure of 90/60 mmHg and a heart rate of 86 beats per min, in a regular rhythm. The abdomen was elevated above the chest level, moving actively with respiration. The abdomen appeared moderately distended, with soft, elastic abdominal walls and spontaneous, palpable pain localized in the upper half and the left upper quadrant. The Blumberg sign was inconclusive (±), and flabby peristalsis was noted. Bilateral kidney percussion was negative. The limbs were mobile, without any fractures or swelling.

The patient had a standard preoperative consultation with a cardiologist and an anesthesiologist. Blood tests conducted prior to surgery revealed the findings summarized in Table 1. The abdominal ultrasound detected ascites, and the liver appeared enlarged, measuring 193 mm in the right mid-clavicular line, with an isoechoic structure and no convincing ultrasound evidence of focal lesions. The gallbladder was of maintained size and wall integrity, with polypoid growth observed on the dorsal wall. Non-dilated intra- and extrahepatic bile ducts were noted. The pancreas was not visualized for examination. Regarding the spleen, a non-uniform hyperechoic zone, approximately 77 mm in length along the lateral contour, suspicious for a hematoma, was found. Both kidneys were normal in topography, shape, and size, with preserved parenchyma and drainage. A calculus was observed in the left renal pelvis, along with a parenchymal cyst in the left kidney measuring 51 mm in diameter. The bladder was found to be empty.

Table 1.

Patient’s laboratory results compared with reference ranges.

Variable	Patient’s result	Reference range
Hemoglobin	87.0 g/L	140–180 g/L
Red blood cell count	2.81×1012/L	4.5–6×1012/L
Hematocrit	0.263 L/L	0.40–0.54 L/L
Mean corpuscular volume	93.5 fL	82–98 fL
Mean corpuscular hemoglobin	31.1 pg	27–33 pg
Mean corpuscular hemoglobin concentration	333.0 g/L	300–360 g/L
Red blood cell distribution width	15.1%	11–16%
White blood cell count	28.41×109/L	3.5–10.5×109/L
Platelet count	294.0×109/L	140–400×109/L
Mean platelet volume	9.9 fL	7.2–11.2 fL
Procalcitonin	0.291%	0.109–0.485%
Platelet distribution width	11.0%	8–65%
Glucose	9.6 mmol/L	2.8–6.1 mmol/L
Total bilirubin	12.1 µmol/L	3.4–21 µmol/L
Direct bilirubin	2.5 µmol/L	0.8–8.5 µmol/L
Creatinine	342.0 µmol/L	74–134 µmol/L
Urea	18.06 mmol/L	3.2–8.2 mmol/L
Total protein	55.9 g/L	60–83 g/L
Albumin	35.0 g/L	35–52 g/L
C-reactive protein	23.0 mg/L	0–10 mg/L
Aspartate transaminase	37.0 U/L	0–50 U/L
Alanine transaminase	22.0 U/L	0–50 U/L
Lactate dehydrogenase	657.0 U/L	230–460 U/L
Amylase	48.0 U/L	28–100 U/L
Potassium	5.2 mmol/L	3.5–5.6 mmol/L
Sodium	142.0 mmol/L	136–151 mmol/L
Chloride	103.0 mmol/L	96–110 mmol/L
Calcium	1.99 mmol/L	2.12.–2.62 mmol/L
International normalized ratio	1.0	0.8–1.2
Activated partial thromboplastin time	22.6 σ	24–35 s
Fibrinogen	2.88 g/L	2.0–4.5 g/L
Thrombin time	15.2 s	14–21 s

In conclusion, ultrasound imaging revealed ascites, a suspected splenic hematoma, left-sided nephrolithiasis, and a kidney cyst. Considering these findings, further investigations were warranted to confirm the diagnosis and guide treatment.

An abdominal native computed tomography (CT) scan was performed urgently without contrast enhancement, due to azotemia, and showed a high-density heterogeneous fluid collection at the top of the spleen, which was not well distinguished. No gross contusion marks on the other parenchymal organs were found. Perihepatic and interpleural liquid collections with a density of 20 to 30 HU were detected. The lumbar vertebrae and spinal canal were intact. Bilateral nephrolithiasis with a 10-mm calculus on the left and a 6-mm to 7-mm calculus in the gallbladder were observed.

The abdominal CT scan revealed evidence of splenic rupture with intraperitoneal fluid, suggestive of hemoperitoneum, as visible in Figure 1.

Figure 1.

Computed tomography scan slice depicting free peritoneal fluid and splenic rupture. The scan showed a high-density, heterogeneous fluid collection at the splenic apex and near the liver, as indicated by the left arrow, suggestive of hemoperitoneum. The enlargement of the spleen and indistinct borders, marked by the right arrow, suggest rupture.

The native pelvis CT showed fluid collection with a density of 20 to 30 HU, a urinary bladder with smooth contours, and a catheter placed. The bones of the pelvic ring were without traumatic changes. In summary, a high-protein free fluid was noted, with no evidence of traumatic changes to the pelvic structures.

Following confirmation of a ruptured spleen, the patient underwent prompt resuscitation and emergency surgery. The type of anesthesia was general endotracheal, using Sevorane.

Intraoperative diagnosis confirmed the preoperative findings of ruptura lienis and hemoperitoneum.

Abdominal exploration via laparotomy revealed approximately 2000 mL of old venous blood and clots bilaterally in the perihepatic and perisplenic regions, extending to the pelvis. A complete splenic rupture (grade IV) was identified.

Splenectomy was performed after luxation and mobilization. The lienal artery and vein, along with the a. and v. gastric breves were ligated and sutured at the splenic hilum (Figures 2, 3). The peritoneal cavity was thoroughly irrigated until the lavage fluid ran clear. After a secondary careful revision, no other traumatic lesions in the parenchymal and hollow viscus abdominal organs were found. Three No. 28 drains were inserted as follows: the first in contact with the bed of the spleen, the second in the right lateral canal, and the third in the small pelvis. The integrity of the abdominal wall was restored layer by layer.

Figure 2.

Mobilized Spleen. The image shows the spleen after it had been mobilized during the open splenectomy procedure. The surrounding ligaments were divided, and the extensive rupture is clearly visible.

Figure 3.

Splenectomy. This figure illustrates the clamping of the lienal artery and vein, along with the short gastric arteries and veins at the splenic hilum during the surgical procedure. This surgical step ensures proper isolation and control of vascular structures before spleen removal, which is essential for the success of the procedure.

Excisional biopsy uncovered splenic tissue with capsular and trabecular fibrosis and hemorrhages upon examination of 1 paraffin block.

A nephrologist conducted a postoperative assessment of the patient. Preoperative laboratory findings revealed a creatinine level of 342 μmol/L (reference range, 74–134) and a urea level of 18 mmol/L (reference range, 3.2–8.2). Postoperative evaluation demonstrated a decrease in these values to creatinine 264 μmol/L and urea 16.9 mmol/L. The electrolyte panel revealed hypocalcemia, while potassium levels remained within the normal range. The patient, with a urinary catheter in place, produced 1500 mL of concentrated urine over a 24-h period. The recommendations included daily intravenous fluids ranging from 2000 to 2500 mL, continuous monitoring of blood pressure and diuresis, and the intravenous administration of 2 ampoules of calcium gluconate.

The patient’s treatment plan included 6 units of packed red blood cells (Er mass), 3 units of fresh frozen plasma, 2500 mL of intravenous crystalloids, Metamysole/Tramalgin (2×1), Flagyl (2×500 mg), Cefotaxime (2×1), Pantoprazole (2×1), Clexane 0.4 mg, Degan (2×1), and 2 ampoules of calcium gluconate.

The postoperative course was uneventful, characterized by primary wound healing, restoration of bowel function, and maintenance of normal body temperature throughout the hospital stay. Abdominal examination at discharge revealed a soft, non-tender abdomen with normal respiratory movements and physiological peristalsis.

No complications were encountered, and the patient was discharged home on postoperative day 7.

Discussion

ESWL can cause various extrarenal injuries, such as intra-abdominal bleeding or abscess, liver and pancreatic hematomas, acute pancreatitis, pulmonary contusion and hemoptysis, pneumothorax, urinothorax, perforation of the bowel, rupture of the abdominal aorta, hepatic artery, and iliac artery, and splenic rupture and abscess [2]. Splenic trauma has been described as an exceedingly rare complication of ESWL.

Splenic injury likely results from unintentional movement during the sound wave administration for the stone fragmentation procedure. Utilizing noise cancelling headphones during ESWL can preclude the potential pitfalls of patient nervousness [1].

Special care should be given to patients undergoing ESWL under general anesthesia, especially if they have known splenic abnormalities, such as those caused by leukemia or lymphoma [3]. In case of the Kehr sign or generalized upper-quadrant pain after ESWL, splenic rupture should always be ruled out. Splenectomy is often necessary; however, if the patient is hemodynamically stable, non-operative management (NOM) can be attempted with close follow-up in a monitored setting, such as a high dependency unit or intensive care unit [4,5].

Only 12 cases of splenic rupture following extracorporeal shock wave lithotripsy are published with full text in the available literature [1,5–15]. Due to insufficient information, abstracts or restricted access articles on ESWL spleen injury were not included in Table 2.

Table 2.

Global extracorporeal shockwave lithotripsy spleen rupture cases published in full text in the available literature.

Ref	Author	Patient age (Yrs)	Patient sex	Time to surgery in hours	Spleen trauma grade	Hemoglobin values	Total received shocks	Power	Complications & outcome
1	Marinkovic 2015	54	Male	Before 24	III	NA	2500	6	Uneventful
5	Raeymaeckers 2017	41	Male	NOM	I	9.9 g/dL	NA	NA	Uneventful
6	Marcuzzi 1991	70	Male	After 24	III	67 gm/1	6,000	19	Uneventful
7	Rashid 1996	60	Female	Before 24	NA	10.3 g/dL	3000	24	NA
8	Fugita 1998	37	Male	After 24	III	9.9 g/dL	2400	24	Uneventful
9	Kastelan 2005	54	Male	Before 24	III	NA	2500	14.9	Uneventful
10	White 2008	61	Female	After 24	IV	NA	NA	NA	Uneventful
11	Willekens 2015	41	Male	NOM	I	NA	NA	NA	Uneventful
12	Chacon 2016	62	Female	After 24	IV	NA	NA	NA	Uneventful
13	Zodda 2017	70	Male	After 24	III	11.3 g/dL	NA	NA	Uneventful
14	Salih 2020	33	Male	NOM	I	NA	2500	1 to 7	Uneventful
15	Patel 2020	82	Female	Before 24	III	7.2 g/dL	NA	NA	Uneventful

NA – not available; NOM – non-operative management.

The spleen trauma grade (Table 2) was estimated approximately based on the clinical data of each case. The age of the studied patients ranged from 33 to 82 years, with a sex ratio of 8 males to 4 females. Three of the patients were treated by NOM. An uneventful recovery was observed in all cases. Comparing the patient and author data of Raeymaeckers et al (2017) in the Journal of Clinical Urology and those of Willekens et al (2015) published in the Journal of the Belgian Society of Radiology, they were considered one and the same [5,11].

In our case, a 72-year-old man developed clinical signs of spleen injury 24 h after ESWL, manifesting as acute abdomen and severe progressive hemorrhagic anemia. As a result, an emergency laparotomy and splenectomy were required. He did not have any splenic anomalies previously. At the 1-month follow-up, the patient’s hematologic, hemostatic, liver, and kidney indices were within reference limits, without somatic or functional deficits.

To improve the success rates and safety of ESWL, suggestions for new treatment strategies are based on multiple studies of the renal response to shock waves and the mechanisms of shock wave action in stone breakage and renal injury [14,16].

Currently, the 12 case reports of splenic rupture describe splenectomy as the criterion standard treatment. However, NOM serves as a pragmatic alternative to splenectomy following shockwave lithotripsy. Whenever possible, choosing to apply NOM to spare the spleen and prevent the risk of post-splenectomy syndrome is advisable.

Over the past few decades, the management of splenic trauma has significantly evolved, with a pronounced shift toward NOM. According to the World Society of Emergency Surgery guidelines and recommendations, various strategies are outlined for selecting this treatment option for adult patients with spleen trauma:

• Patients who are hemodynamically stable and do not have other abdominal organ injuries requiring surgery should initially undergo NOM, regardless of the severity of their splenic injury [17].

• For moderate or severe spleen injuries, NOM should only be considered in settings equipped with intensive patient monitoring capabilities, angiography or angioembolization services, immediate access to an operating room, and the availability of blood products [17].

• NOM is contraindicated in cases of unresponsive hemodynamic instability or other indications for laparotomy, including peritonitis, hollow organ injuries, and bowel evisceration [17].

• Operative management should be conducted in patients with hemodynamic instability, and splenectomy is necessary when NOM with angiography or angioembolization services fails, resulting in persistent hemodynamic instability and a significant drop in hematocrit levels [17].

Despite being noninvasive, SWL encounters limitations and challenges that can influence treatment outcomes. Patient selection is crucial for SWL success rates, and various clinical nomograms aim to identify optimal factors based on stone-free rates. Predictors include clinical data, such as age, sex, body weight, and body mass index, as well as CT scan-based factors, such as stone location, number, diameter, Hounsfield units, and the presence of hydronephrosis [18]. Some patient-related factors, such as obesity and a longer skin-to-stone distance, negatively affect SWL success rates [19]. The energy level of shock waves also plays a pivotal role in stone fragmentation. Inadequate energy might result in insufficient fragmentation, while excessive energy can lead to tissue injury. The future of SWL is expected to be shaped by evolving lithotripter designs, integration of advanced imaging and tracking technologies, refined treatment protocols, and personalized treatment algorithms [20].

Conclusions

Splenic lesions are an exceptional but serious complication following ESWL, marking the importance of prompt diagnosis and intervention. The management of splenic trauma requires a multidisciplinary approach, considering physiological, anatomical, and immunological factors. Using modern tools for bleeding management enables more effective decision making, considering the injury’s anatomy, physiological consequences, and associated lesions. While splenectomy is the conventional treatment, NOM can be considered for hemodynamically stable patients to avoid post-splenectomy complications. Our case underscores the importance of monitoring for splenic injury after ESWL.

The recognized risk of injury accompanying ESWL remains, but the adoption of refined treatment protocols has led to significant improvements in stone fragmentation and a notable reduction in acute tissue damage. This progress offers optimism for substantial mitigation, if not total elimination, of long-term adverse effects.