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Delayed rupture of spleen in a case of spouse abuse
Journal of Clinical Fotz,nsic Medicine (1999)6, 243245 © APS/HarcourtPublishersLtd 1999
CASE R E P O R T
Delayed rupture of spleen in a case of spouse abuse N. Abeyasinghe Department of Forensic Medicine and Toxicology, Faculty of Medicine Colombo, Sri Lanka SUMMARY. This case deals with assault of a housewife by her husband. Although there had been previous episodes of abuse, the gravity of the present injury, which required hospitalization, resulted in the fact being made known to others. Insistence on a wife's right to protection and shelter from a husband who assaults her has grown significantly in the wake of the women's liberation movement. However, it remains the case that few women in Sri Lanka would take action and risk disrupting their families. © APS/Harcourt Publishers Ltd 1999
Journal of Clinical Forensic ~ledicine (1999) 6, 243-245
not be performed due to the intense pain felt by the patient. Investigations showed: Hb of 9.7 g/dl, white cell count 10 600 (84% neutrophils, 16% lymphocytes), blood urea 17 rag%, Serum Na 127 meq/L, Serum K 4.2 meq/L. Exploratory laparotomy performed the same day revealed a haemoperitoneum with of l L of blood clot. There was a blood clot within the capsule of the spleen. The lower pole of the spleen and its capsule were torn. A splenectomy was performed. The stomach, intestines, liver, ovaries and tubes were healthy. The patient was transfused and made a good recovery. Histology showed dissociation of the parenchyma with haemorrhage and surrounding inflammation within the substance of the spleen.
CASE REPORT
A 24-year-old housewife, was repeatedly abused by her husband, a manual labourer who often returned home drunk. On the 1st April, 1994, after using abusive language, he kicked her in the abdomen. She had felt pain in the upper left region of her abdomen. Over the next few days, she noticed a bluish discolouration developing over the region of assault. On the 9th of April, she had difficulty in breathing. The pain in the left side of her abdomen had worsened and had also extended to the left shoulder. On the 10th of April, she had unbearable abdominal pain with vomiting and diarrhoea after which she had been taken to hospital. She had no history of any medical illnesses such as malaria or any other infectious diseases and no history of depressive episodes. She had been subject to similar assaults whilst her husba~ad was under the influence of alcohol. They had been married for 9 years and had three young children. On admission to hospital, she was pale and afebrile. She was in severe pain and had respiratory distress. There was no jaundice or lymphadenopathy. No external injuries were noted. There was no rib tenderness. The abdomen was tender with rigidity, guarding and flank dullness. An ultrasound scan revealed free fluid in the lower abdomen, with an altered echo pattern at the lower border of the spleen. The left kidney was healthy. Further scanning could
DISCUSSION Traumatic rupture of a healthy spleen is rare. This may be, in part, due to its well protected position in the left upper quadrant of the abdomen. 1Splenic rupture may be seen after severe localized trauma, such as kicking, or when it is damaged along with other abdominal organs following a violent crushing impact5 The spleen can be damaged either from impact on its surface or from traction on its pedicle. 3 The extent of injury is dependent upon the severity of the force applied, and whether it is localized or generalized. 1 Injuries may range from a superficial laceration to virtual disintegration of the spleen. Laceration of the spleen is usually transcapsular, and may take the form of tears across the hilar or convex
Dr N. Abeyasinghe, 51A Ward Place, Colombo 7, Sri Lanka 243
244
Journal of Clinical Forensic Medicine
surface of the spleen. The spleen will rupture immediately as a result of a transcapsular laceration. Due to the vascular nature of the spleen, haemorrhage into the peritoneal cavity from a splenic laceration or from a tear in the pedicle is often profuse. In some instances, the force delivered to the spleen is sufficient to lacerate the splenic parenchyma, but not to injure the capsule. If internal bleeding continues, a subcapsular haematoma may form, and with progressive increase in the subcapsular pressure, rupture of the capsule and the resultant intraperitoneal haemorrhage may be delayed by days or weeks. 2 It has been reported as late as 6 months and even 2 years after the event. <8 This patient had a subcapsular haematoma with a laceration of the spleen and its capsule, hence the delayed onset of the splenic rupture. Subcapsular haemorrhage is the most common aetiology for delayed splenic rupture. Delayed splenic rupture is a rare event. A study on patients with blunt splenic injury revealed that severe trauma, such as that occurring with motor vehicle accidents, is more likely to lead to immediate rupture. Lesser trauma resulting from minor falls or fights is more likely to lead to delayed rupture? At times, the haematoma may stop enlarging after a time and resolve, leaving an area of scarring. Severe fatal internal haemorrhage due to a ruptured spleen may occur without any sign of injury on the abdominal wall. The bluish discolouration described by the patient in the early days following the assault, may have been a contusion, though it was not apparent at the time of admission to hospital. Lacerations of the spleen may or may not be accompanied by fractures of the overlying ribs. When a diseased spleen ruptures, severe bleeding may take place in a short time, probably as an enlarged spleen is more vulnerable and fragile than a normal organ. Malaria, glandular fever, malignant turnouts, infections, inflammatory diseases, connective tissue diseases and other miscellaneous disorders have been known to increase the risk of rupture. 6 In athletes or those employed in strenuous occupations, the spleen may be physiologically enlarged. 2 This did not apply to this patient. The spleen size was within the normal range, and the histology report indicated the presence of a tear with haemorrhage and surrounding inflammation within the substance of the spleen. The above case history was that of a delayed rupture of the spleen which could have led to death had there been no surgical intervention. Initially, due to the direct impact and resulting contusion of the abdominal wall, the patient had felt pain. About 9 days later, with rupture of the subcapsular haematoma and leakage of blood into the peritoneal
cavity, she experienced pain and difficulty in breathing, and shoulder tip pain due to irritation of the phrenic nerves on the diaphragm. 7 Although there is no reliable symptom or sign during the latent period, abdominal pain occurs almost uniformly. The pallor, with flank dullness, abdominal pain, guarding and rigidity were indicative of intra-peritoneal bleeding. X-rays helped to exclude rib fractures. They may also show scalloping of the gastric shadow along the greater curvature where the haemorrhage has extravasated the short gastric arteries causing an extraluminal haematoma on the gastric wall. Serial films showing an enlarged splenic shadow may also help. Other procedures, such as isotope scintiscanning for abnormal splenic contour, may also be used. In this patient, the ultrasound scan confirmed the presence of intra-peritoneal bleeding with abnormality at the lower border of the spleen. Whenever splenic injury is strongly suspected, the decision to manage conservatively or invasively would depend on the haemodynamic status of the individual?, 9 Recognition of the important role of the spleen within the immune system has prompted surgeons to regularly consider splenic preservation. L°In this patient, exploratory laparotomy was indicated, as her symptoms were progressive, and by the time she came to hospital there were obvious signs of active intra-peritoneal bleeding. A splenectomy was necessary in order to save her life. Since her injury required active intervention in order to save her life, the injury was categorized as being 'fatal in the ordinary course of nature' according to the Penal Code of Sri Lanka. The offence a perpetrator would be charged with for such an injury would be one of 'attempted murder'. In a survey of 200 such cases of battered wives, Gayford noted the common injuries as being contusions caused by a fist or by being kicked. H Lacerations, cut injuries, burns and scalds were less commonly seen. This victim fitted into the commoner injury pattern. The association of alcohol with the violence is seen in a large percentage of cases, as it was in this incident. One study showed an association with alcohol of 50%. 12It was also noted that most of the husbands who assaulted their wives had psychological symptoms as well. According to this patient, however, her husband was quite normal and treated her well apart from the periods when he was under the influence of alcohol. Although this victims's husband could have been charged for 'attempted murder' according to section 294 of the Penal Code of Sri Lanka, she was reluctant to press charges as she did not wish any further complications in her marriage. It was only during times of excessive alcohol indulgence that her husband
D e l a y e d r u p t u r e o f spleen
a s s a u l t e d her. A l t h o u g h there was little she c o u l d d o to p r o t e c t herself, she d i d n o t wish her children to u n d e r g o any m e n t a l t r a u m a as a result o f legal a c t i o n t a k e n by her. It is very rare that a w o m a n takes h e r c o h a b i t i n g h u s b a n d to court, p a r t i c u l a r l y when she has children a n d does n o t wish to d i s r u p t their lives. T h e r e can be no surprise that so m a n y w o m e n either fail to press charges o r d r o p t h e m before the c o u r t hearing. A s i a n w o m e n have g r o w n up in a culture where they are expected to b e a r such physical abuse s h o u l d it occur. Studies d o n e on different cultures have shown that attitudes a n d p e r c e p t i o n s o f s p o u s a l abuse are culturally related? 3 Recently, however, there has been a c o n c e r t e d a t t e m p t at a n a t i o n a l level, to e n h a n c e the rights o f w o m e n . Even i f a w o m a n has the d e t e r m i n a tion to continue, she w o u l d find p r o b a t i o n a n d susp e n d e d sentence o f little help, as her h u s b a n d c o u l d try to prevent her r e a p p e a r a n c e in c o u r t with violence. A b e t t e r alternative m a y be r e h a b i l i t a t i o n a n d c o u n selling for families, with r e g a r d to a l c o h o l problems. C e r t a i n o r g a n i z a t i o n s in Sri L a n k a such as W o m e n I n N e e d , A l c o h o l i c s A n o n y m o u s , cater for families u n d e r g o i n g such problems. This victim was i n s t r u c t e d to visit the counselling centres in o r d e r to o b t a i n f u r t h e r s u p p o r t for her p r o b l e m .
245
REFERENCES
1. DeMaio DL DeMaio VJM. Forensic Pathology. Boca Raton: CRC Press, 1989; 127. 2. Mant AK (ed.). Taylor's principles and practice of medical jurisprudence, 13th edn. Edinburgh: Churchill Livingstone 1984; 237. 3. Gordon I, Shapiro HA, Berson SD. Forensic Medicine a guide to principles, 3rd edn. Edinburgh: Churchill Livingstone 1988; 314. 4. Eernandes CM. Splenic rupture manifesting two years after diagnosis of injury. Acad Emerg Med 1996; 3(10): 946-947. 5. Farhat GA, Abdu RA, Vanek VW Delayed splenic rupture: real or imaginery? Am Surg 1992; 58(6): 340-345. 6. Knight B. Forensic Pathology, 1st edn. London: Edward Arnold 1991; 208. 7. Clark OH, Lira RC, Margaretten W. Spontaneous delayed splenic rupture. J Trauma 1975; 15(3): 245-249. 8. Hamour OA, Kashgari RH, AI Harbi MA, Azmi A. Splenic preservation after traumatic rupture. A remote hospital experience. Int-Surg 1996; 81(3): 304 308. 9. Wasvary H, Howells G, Villalba M et al. Non-operative management of adult blunt splenic trauma: a 15 year experience. Am Surg 1997; 63(8): 694-699. 10. Clancy TV, Weintritt DC, Ramshaw DG, Churchill MR Corington DL, Maxwell JG. Splenic salvage in adults at a level II community hospital trauma center. Am Surg 1996; 62(12): i045-1049. 11. Gayford JJ. Battered wives. Med Sci Law 1975; 15(4): 237. 12. Mason JK. Pathology of violent injury, 1st edn. London: Edward Arnold, 1978; 230 13. Gabler M, Stern SE, Miserandino M. Latin American, Asian and American cultural differences in perceptions of spousal abuse. PsychoI Rep 1998; 83(2): 587 592.
CASE R E P O R T
Delayed rupture of spleen in a case of spouse abuse N. Abeyasinghe Department of Forensic Medicine and Toxicology, Faculty of Medicine Colombo, Sri Lanka SUMMARY. This case deals with assault of a housewife by her husband. Although there had been previous episodes of abuse, the gravity of the present injury, which required hospitalization, resulted in the fact being made known to others. Insistence on a wife's right to protection and shelter from a husband who assaults her has grown significantly in the wake of the women's liberation movement. However, it remains the case that few women in Sri Lanka would take action and risk disrupting their families. © APS/Harcourt Publishers Ltd 1999
Journal of Clinical Forensic ~ledicine (1999) 6, 243-245
not be performed due to the intense pain felt by the patient. Investigations showed: Hb of 9.7 g/dl, white cell count 10 600 (84% neutrophils, 16% lymphocytes), blood urea 17 rag%, Serum Na 127 meq/L, Serum K 4.2 meq/L. Exploratory laparotomy performed the same day revealed a haemoperitoneum with of l L of blood clot. There was a blood clot within the capsule of the spleen. The lower pole of the spleen and its capsule were torn. A splenectomy was performed. The stomach, intestines, liver, ovaries and tubes were healthy. The patient was transfused and made a good recovery. Histology showed dissociation of the parenchyma with haemorrhage and surrounding inflammation within the substance of the spleen.
CASE REPORT
A 24-year-old housewife, was repeatedly abused by her husband, a manual labourer who often returned home drunk. On the 1st April, 1994, after using abusive language, he kicked her in the abdomen. She had felt pain in the upper left region of her abdomen. Over the next few days, she noticed a bluish discolouration developing over the region of assault. On the 9th of April, she had difficulty in breathing. The pain in the left side of her abdomen had worsened and had also extended to the left shoulder. On the 10th of April, she had unbearable abdominal pain with vomiting and diarrhoea after which she had been taken to hospital. She had no history of any medical illnesses such as malaria or any other infectious diseases and no history of depressive episodes. She had been subject to similar assaults whilst her husba~ad was under the influence of alcohol. They had been married for 9 years and had three young children. On admission to hospital, she was pale and afebrile. She was in severe pain and had respiratory distress. There was no jaundice or lymphadenopathy. No external injuries were noted. There was no rib tenderness. The abdomen was tender with rigidity, guarding and flank dullness. An ultrasound scan revealed free fluid in the lower abdomen, with an altered echo pattern at the lower border of the spleen. The left kidney was healthy. Further scanning could
DISCUSSION Traumatic rupture of a healthy spleen is rare. This may be, in part, due to its well protected position in the left upper quadrant of the abdomen. 1Splenic rupture may be seen after severe localized trauma, such as kicking, or when it is damaged along with other abdominal organs following a violent crushing impact5 The spleen can be damaged either from impact on its surface or from traction on its pedicle. 3 The extent of injury is dependent upon the severity of the force applied, and whether it is localized or generalized. 1 Injuries may range from a superficial laceration to virtual disintegration of the spleen. Laceration of the spleen is usually transcapsular, and may take the form of tears across the hilar or convex
Dr N. Abeyasinghe, 51A Ward Place, Colombo 7, Sri Lanka 243
244
Journal of Clinical Forensic Medicine
surface of the spleen. The spleen will rupture immediately as a result of a transcapsular laceration. Due to the vascular nature of the spleen, haemorrhage into the peritoneal cavity from a splenic laceration or from a tear in the pedicle is often profuse. In some instances, the force delivered to the spleen is sufficient to lacerate the splenic parenchyma, but not to injure the capsule. If internal bleeding continues, a subcapsular haematoma may form, and with progressive increase in the subcapsular pressure, rupture of the capsule and the resultant intraperitoneal haemorrhage may be delayed by days or weeks. 2 It has been reported as late as 6 months and even 2 years after the event. <8 This patient had a subcapsular haematoma with a laceration of the spleen and its capsule, hence the delayed onset of the splenic rupture. Subcapsular haemorrhage is the most common aetiology for delayed splenic rupture. Delayed splenic rupture is a rare event. A study on patients with blunt splenic injury revealed that severe trauma, such as that occurring with motor vehicle accidents, is more likely to lead to immediate rupture. Lesser trauma resulting from minor falls or fights is more likely to lead to delayed rupture? At times, the haematoma may stop enlarging after a time and resolve, leaving an area of scarring. Severe fatal internal haemorrhage due to a ruptured spleen may occur without any sign of injury on the abdominal wall. The bluish discolouration described by the patient in the early days following the assault, may have been a contusion, though it was not apparent at the time of admission to hospital. Lacerations of the spleen may or may not be accompanied by fractures of the overlying ribs. When a diseased spleen ruptures, severe bleeding may take place in a short time, probably as an enlarged spleen is more vulnerable and fragile than a normal organ. Malaria, glandular fever, malignant turnouts, infections, inflammatory diseases, connective tissue diseases and other miscellaneous disorders have been known to increase the risk of rupture. 6 In athletes or those employed in strenuous occupations, the spleen may be physiologically enlarged. 2 This did not apply to this patient. The spleen size was within the normal range, and the histology report indicated the presence of a tear with haemorrhage and surrounding inflammation within the substance of the spleen. The above case history was that of a delayed rupture of the spleen which could have led to death had there been no surgical intervention. Initially, due to the direct impact and resulting contusion of the abdominal wall, the patient had felt pain. About 9 days later, with rupture of the subcapsular haematoma and leakage of blood into the peritoneal
cavity, she experienced pain and difficulty in breathing, and shoulder tip pain due to irritation of the phrenic nerves on the diaphragm. 7 Although there is no reliable symptom or sign during the latent period, abdominal pain occurs almost uniformly. The pallor, with flank dullness, abdominal pain, guarding and rigidity were indicative of intra-peritoneal bleeding. X-rays helped to exclude rib fractures. They may also show scalloping of the gastric shadow along the greater curvature where the haemorrhage has extravasated the short gastric arteries causing an extraluminal haematoma on the gastric wall. Serial films showing an enlarged splenic shadow may also help. Other procedures, such as isotope scintiscanning for abnormal splenic contour, may also be used. In this patient, the ultrasound scan confirmed the presence of intra-peritoneal bleeding with abnormality at the lower border of the spleen. Whenever splenic injury is strongly suspected, the decision to manage conservatively or invasively would depend on the haemodynamic status of the individual?, 9 Recognition of the important role of the spleen within the immune system has prompted surgeons to regularly consider splenic preservation. L°In this patient, exploratory laparotomy was indicated, as her symptoms were progressive, and by the time she came to hospital there were obvious signs of active intra-peritoneal bleeding. A splenectomy was necessary in order to save her life. Since her injury required active intervention in order to save her life, the injury was categorized as being 'fatal in the ordinary course of nature' according to the Penal Code of Sri Lanka. The offence a perpetrator would be charged with for such an injury would be one of 'attempted murder'. In a survey of 200 such cases of battered wives, Gayford noted the common injuries as being contusions caused by a fist or by being kicked. H Lacerations, cut injuries, burns and scalds were less commonly seen. This victim fitted into the commoner injury pattern. The association of alcohol with the violence is seen in a large percentage of cases, as it was in this incident. One study showed an association with alcohol of 50%. 12It was also noted that most of the husbands who assaulted their wives had psychological symptoms as well. According to this patient, however, her husband was quite normal and treated her well apart from the periods when he was under the influence of alcohol. Although this victims's husband could have been charged for 'attempted murder' according to section 294 of the Penal Code of Sri Lanka, she was reluctant to press charges as she did not wish any further complications in her marriage. It was only during times of excessive alcohol indulgence that her husband
D e l a y e d r u p t u r e o f spleen
a s s a u l t e d her. A l t h o u g h there was little she c o u l d d o to p r o t e c t herself, she d i d n o t wish her children to u n d e r g o any m e n t a l t r a u m a as a result o f legal a c t i o n t a k e n by her. It is very rare that a w o m a n takes h e r c o h a b i t i n g h u s b a n d to court, p a r t i c u l a r l y when she has children a n d does n o t wish to d i s r u p t their lives. T h e r e can be no surprise that so m a n y w o m e n either fail to press charges o r d r o p t h e m before the c o u r t hearing. A s i a n w o m e n have g r o w n up in a culture where they are expected to b e a r such physical abuse s h o u l d it occur. Studies d o n e on different cultures have shown that attitudes a n d p e r c e p t i o n s o f s p o u s a l abuse are culturally related? 3 Recently, however, there has been a c o n c e r t e d a t t e m p t at a n a t i o n a l level, to e n h a n c e the rights o f w o m e n . Even i f a w o m a n has the d e t e r m i n a tion to continue, she w o u l d find p r o b a t i o n a n d susp e n d e d sentence o f little help, as her h u s b a n d c o u l d try to prevent her r e a p p e a r a n c e in c o u r t with violence. A b e t t e r alternative m a y be r e h a b i l i t a t i o n a n d c o u n selling for families, with r e g a r d to a l c o h o l problems. C e r t a i n o r g a n i z a t i o n s in Sri L a n k a such as W o m e n I n N e e d , A l c o h o l i c s A n o n y m o u s , cater for families u n d e r g o i n g such problems. This victim was i n s t r u c t e d to visit the counselling centres in o r d e r to o b t a i n f u r t h e r s u p p o r t for her p r o b l e m .
245
REFERENCES
1. DeMaio DL DeMaio VJM. Forensic Pathology. Boca Raton: CRC Press, 1989; 127. 2. Mant AK (ed.). Taylor's principles and practice of medical jurisprudence, 13th edn. Edinburgh: Churchill Livingstone 1984; 237. 3. Gordon I, Shapiro HA, Berson SD. Forensic Medicine a guide to principles, 3rd edn. Edinburgh: Churchill Livingstone 1988; 314. 4. Eernandes CM. Splenic rupture manifesting two years after diagnosis of injury. Acad Emerg Med 1996; 3(10): 946-947. 5. Farhat GA, Abdu RA, Vanek VW Delayed splenic rupture: real or imaginery? Am Surg 1992; 58(6): 340-345. 6. Knight B. Forensic Pathology, 1st edn. London: Edward Arnold 1991; 208. 7. Clark OH, Lira RC, Margaretten W. Spontaneous delayed splenic rupture. J Trauma 1975; 15(3): 245-249. 8. Hamour OA, Kashgari RH, AI Harbi MA, Azmi A. Splenic preservation after traumatic rupture. A remote hospital experience. Int-Surg 1996; 81(3): 304 308. 9. Wasvary H, Howells G, Villalba M et al. Non-operative management of adult blunt splenic trauma: a 15 year experience. Am Surg 1997; 63(8): 694-699. 10. Clancy TV, Weintritt DC, Ramshaw DG, Churchill MR Corington DL, Maxwell JG. Splenic salvage in adults at a level II community hospital trauma center. Am Surg 1996; 62(12): i045-1049. 11. Gayford JJ. Battered wives. Med Sci Law 1975; 15(4): 237. 12. Mason JK. Pathology of violent injury, 1st edn. London: Edward Arnold, 1978; 230 13. Gabler M, Stern SE, Miserandino M. Latin American, Asian and American cultural differences in perceptions of spousal abuse. PsychoI Rep 1998; 83(2): 587 592.