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Delayed splenic hematoma: An injury in evolution
Delayed splenic hematoma: An injury in evolution J. Christopher DiGiacomo, MD, Michael F. Rotondo, MD, Donald R. Kauder, MD, and C. William Schwab, MD, Philadelphia, Pa.
From the Division of Traumatology and Surgical Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pa.
THE DIAGNOSTIC CRITERIA FOR THE diagnosis of delayed splenic rupture are a history of blunt abdominal trauma with no clinical evidence of intraabdominal injury, a normal appearance of the spleen by computed tomographic (CT) scan of the abdomen at the initial evaluation, and subsequent documentation of splenic rupture.1 According to these criteria, there are few cases of true delayed splenic rupture in the literature.1-5 Fundamental to this paradigm is the concept of delayed splenic hematoma. In contradistinction to delayed splenic rupture, however, little attention has been paid to the delayed development of a splenic hematoma.3,6 We report a case in which the evolution of a splenic hematoma was documented over time. CASE REPORT A 47-year-old male unrestrained driver was struck by another vehicle on the driver’s (left) side. The extrication time was 20 minutes and total prehospital time was approximately 1 hour. On arrival at the trauma center, his blood pressure was 147/87 mm Hg, pulse 123 beats/min, and respirations 24/min. His Glasgow Coma Scale score was 15. Secondary survey and plain x-ray films revealed a left-side scalp laceration, fractures of the left seventh to ninth and right seventh ribs, and a comminuted left tibial and fibular fracture. Results of laboratory and coagulation studies were normal. An abdominal CT scan with oral gastrointestinal and nonionic iodinated intravenous contrast material was performed on a General Electric 9800 computer-assisted tomographic unit approximately 40 minutes after arrival in the trauma admitting area. The enteral portion consisted of 10 ml gastrointestinal contrast material diluted in 360 ml saline solution. The intravenous portion consisted of 150 ml iodinated nonionic contrast agent administered at 2 ml/min. Sequential images from the upper abdomen through the pelvis were obtained beginAccepted for publication June 20, 1997. Reprint requests: J. C. DiGiacomo, MD, 195 Georgia Rd., Freehold, NJ 07728. Surgery 1998;123:478-9. Copyright © 1998 by Mosby, Inc. 0039-6060/98/$5.00 + 0 11/57/84874
478 SURGERY
Fig. 1. Initial CT scan of abdomen performed less than 2 hours after injury. Spleen appears homogeneous and normal. ning 45 seconds after the infusion was begun. The study was initially interpreted by the senior radiology resident on call as normal (Fig. 1), and the patient was taken to the operating room for open reduction and internal fixation of the left leg fractures. While the patient was in the operating room, the abdominal CT scan was reviewed by an attending radiologist, who identified a small amount of fluid around the head of the pancreas. The patient underwent a second abdominal CT scan with 1 mm cuts through the pancreas (approximately 12 hours later) that revealed a small increase in the fluid around the head of the pancreas. A 2 × 3 cm lesion in the parenchyma of the spleen was interpreted as a hemangioma (Fig. 2). The patient underwent exploratory laparotomy to rule out pancreatic injury. At laparotomy no injuries were identified around the pancreas or duodenum. The spleen was visualized in its bed and had no signs of injury. It was not mobilized from the left upper quadrant. The patient’s postoperative course was complicated by ventilatory failure, for which he received a percutaneous tracheostomy on hospital day 10, and pneumonia. Because of persistent fevers and a rising white blood cell count, he underwent another CT scan of the abdomen on hospital day 19 to rule out an intraabdominal nidus of infection. This study revealed a large intrasplenic and subcapsular hematoma in continuity with a splenic laceration (Fig. 3). Compared with the previous study, the location of the splenic laceration correlated with the site initially identified as a hemangioma. Because the
DiGiacomo et al. 479
Surgery Volume 123, Number 4 patient had no periods of hypotension and had maintained stable hemoglobin and hematocrit levels throughout the hospitalization, the splenic hematoma was managed nonoperatively. Subsequent CT scans documented resolution of the hematoma.
DISCUSSION The difference between the delayed diagnosis of splenic injury and the true diagnosis of delayed rupture of the spleen is often unclear. Before the advent of CT, the incidence of delayed splenic rupture was estimated at 15%.1,5,6 However, with the widespread availability of CT scanning, the accepted incidence range has become 1% to 2%.1,5,6 Taylor and Rosenfield2 were the first to use CT scanning to document a case of delayed splenic rupture. This patient had a normal abdominal CT scan in the first hours after injury and was found to have a ruptured spleen 10 days later. The following year Fagelman et al.3 used the CT scan to document the delayed development of a subcapsular hematoma. Since these reports, the majority of patients reported to have delayed splenic rupture had evidence of splenic laceration or subcapsular hematoma on the initial CT scan.5 There have been few patients with normal initial CT scans.1-5 It could be argued that the subcapsular hematoma that developed after the laparotomy was iatrogenic, an injury sustained as a result of inspection of the spleen. We do not believe this to be the case. The spleen was visualized in its bed without mobilization and had no evidence of capsular injury or subcapsular hematoma. The manual portion consisted of palpation of the surface of the spleen without retraction. This case demonstrates that significant splenic subcapsular hematomas can develop after blunt injury in the face of a normal CT scan up to 12 hours after injury (i.e., an injury in evolution). The intraoperative findings of a normal spleen confirmed that the CT scan was not a false-negative result. It has been documented that blood is shunted away from the splanchnic circulation immediately after injury and decreases splenic blood pressure and flow. It may be that with the restoration of splanchnic and splenic pressure and flow, the splenic injury manifests. The relationship between delayed splenic hematoma and delayed rupture of the spleen remains unclear. It seems reasonable to accept the development of a subcapsular splenic hematoma as a risk factor for delayed splenic rupture. However, Black et al.6 reviewed 23 patients who had documented subcapsular splenic hematomas and none progressed to rupture. They concluded that the development of a subcapsular splenic hematoma is not a predictor of delayed splenic rupture. Given the limited number of patients in their review, however, a relationship between the two entities cannot be ruled out.
Fig. 2. Second CT scan of abdomen performed approximately 13 hours after inital study. Note 2 × 3 cm defect in spleen (curved arrow).
Fig. 3. Third CT scan of abdomen obtained on hospital day 19. Note large contained subcapsular splenic hematoma (large arrows) in continuity with intraparenchymal defect noted on previous scan (curved arrow).
Delayed splenic hematoma is a clinical entity, the true incidence of which is unknown, and the relationship to delayed splenic rupture is unclear. It therefore seems prudent to view changes in the splenic parenchyma on serial CT scans as temporal images of an injury in evolution. REFERENCES 1. Kluger Y, Paul DB, Raves JJ, et al. Delayed rupture of the spleen: myths, facts, and their importance—case reports and literature review. J Trauma 1994;36:568-71. 2. Taylor CR, Rosenfield AT. Limitations of computed tomography in recognition of delayed splenic rupture. J Comput Assist Tomogr 1984;8:1205-7. 3. Fagelman D, Hertz MA, Ross AS. Delayed development of subcapsular hematoma: CT evaluation. J Comput Assist Tomogr 1985;9:815-6. 4. Pappas D, Mirvis SE, Crepps JT. Splenic trauma: false-negative CT diagnosis in cases of delayed rupture. AJR Am J Roentgenol 1987;149:727-8. 5. Farhat GA, Abdu RA, Vanek VW. Delayed splenic rupture: real or imaginary? Am Surg 1992;58:340-5. 6. Black JJ, Sinow RM, Wilson SE, Williams RA. Subcapsular hematoma as a predictor of delayed splenic rupture. Am Surg 1992;58:732-5.
From the Division of Traumatology and Surgical Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pa.
THE DIAGNOSTIC CRITERIA FOR THE diagnosis of delayed splenic rupture are a history of blunt abdominal trauma with no clinical evidence of intraabdominal injury, a normal appearance of the spleen by computed tomographic (CT) scan of the abdomen at the initial evaluation, and subsequent documentation of splenic rupture.1 According to these criteria, there are few cases of true delayed splenic rupture in the literature.1-5 Fundamental to this paradigm is the concept of delayed splenic hematoma. In contradistinction to delayed splenic rupture, however, little attention has been paid to the delayed development of a splenic hematoma.3,6 We report a case in which the evolution of a splenic hematoma was documented over time. CASE REPORT A 47-year-old male unrestrained driver was struck by another vehicle on the driver’s (left) side. The extrication time was 20 minutes and total prehospital time was approximately 1 hour. On arrival at the trauma center, his blood pressure was 147/87 mm Hg, pulse 123 beats/min, and respirations 24/min. His Glasgow Coma Scale score was 15. Secondary survey and plain x-ray films revealed a left-side scalp laceration, fractures of the left seventh to ninth and right seventh ribs, and a comminuted left tibial and fibular fracture. Results of laboratory and coagulation studies were normal. An abdominal CT scan with oral gastrointestinal and nonionic iodinated intravenous contrast material was performed on a General Electric 9800 computer-assisted tomographic unit approximately 40 minutes after arrival in the trauma admitting area. The enteral portion consisted of 10 ml gastrointestinal contrast material diluted in 360 ml saline solution. The intravenous portion consisted of 150 ml iodinated nonionic contrast agent administered at 2 ml/min. Sequential images from the upper abdomen through the pelvis were obtained beginAccepted for publication June 20, 1997. Reprint requests: J. C. DiGiacomo, MD, 195 Georgia Rd., Freehold, NJ 07728. Surgery 1998;123:478-9. Copyright © 1998 by Mosby, Inc. 0039-6060/98/$5.00 + 0 11/57/84874
478 SURGERY
Fig. 1. Initial CT scan of abdomen performed less than 2 hours after injury. Spleen appears homogeneous and normal. ning 45 seconds after the infusion was begun. The study was initially interpreted by the senior radiology resident on call as normal (Fig. 1), and the patient was taken to the operating room for open reduction and internal fixation of the left leg fractures. While the patient was in the operating room, the abdominal CT scan was reviewed by an attending radiologist, who identified a small amount of fluid around the head of the pancreas. The patient underwent a second abdominal CT scan with 1 mm cuts through the pancreas (approximately 12 hours later) that revealed a small increase in the fluid around the head of the pancreas. A 2 × 3 cm lesion in the parenchyma of the spleen was interpreted as a hemangioma (Fig. 2). The patient underwent exploratory laparotomy to rule out pancreatic injury. At laparotomy no injuries were identified around the pancreas or duodenum. The spleen was visualized in its bed and had no signs of injury. It was not mobilized from the left upper quadrant. The patient’s postoperative course was complicated by ventilatory failure, for which he received a percutaneous tracheostomy on hospital day 10, and pneumonia. Because of persistent fevers and a rising white blood cell count, he underwent another CT scan of the abdomen on hospital day 19 to rule out an intraabdominal nidus of infection. This study revealed a large intrasplenic and subcapsular hematoma in continuity with a splenic laceration (Fig. 3). Compared with the previous study, the location of the splenic laceration correlated with the site initially identified as a hemangioma. Because the
DiGiacomo et al. 479
Surgery Volume 123, Number 4 patient had no periods of hypotension and had maintained stable hemoglobin and hematocrit levels throughout the hospitalization, the splenic hematoma was managed nonoperatively. Subsequent CT scans documented resolution of the hematoma.
DISCUSSION The difference between the delayed diagnosis of splenic injury and the true diagnosis of delayed rupture of the spleen is often unclear. Before the advent of CT, the incidence of delayed splenic rupture was estimated at 15%.1,5,6 However, with the widespread availability of CT scanning, the accepted incidence range has become 1% to 2%.1,5,6 Taylor and Rosenfield2 were the first to use CT scanning to document a case of delayed splenic rupture. This patient had a normal abdominal CT scan in the first hours after injury and was found to have a ruptured spleen 10 days later. The following year Fagelman et al.3 used the CT scan to document the delayed development of a subcapsular hematoma. Since these reports, the majority of patients reported to have delayed splenic rupture had evidence of splenic laceration or subcapsular hematoma on the initial CT scan.5 There have been few patients with normal initial CT scans.1-5 It could be argued that the subcapsular hematoma that developed after the laparotomy was iatrogenic, an injury sustained as a result of inspection of the spleen. We do not believe this to be the case. The spleen was visualized in its bed without mobilization and had no evidence of capsular injury or subcapsular hematoma. The manual portion consisted of palpation of the surface of the spleen without retraction. This case demonstrates that significant splenic subcapsular hematomas can develop after blunt injury in the face of a normal CT scan up to 12 hours after injury (i.e., an injury in evolution). The intraoperative findings of a normal spleen confirmed that the CT scan was not a false-negative result. It has been documented that blood is shunted away from the splanchnic circulation immediately after injury and decreases splenic blood pressure and flow. It may be that with the restoration of splanchnic and splenic pressure and flow, the splenic injury manifests. The relationship between delayed splenic hematoma and delayed rupture of the spleen remains unclear. It seems reasonable to accept the development of a subcapsular splenic hematoma as a risk factor for delayed splenic rupture. However, Black et al.6 reviewed 23 patients who had documented subcapsular splenic hematomas and none progressed to rupture. They concluded that the development of a subcapsular splenic hematoma is not a predictor of delayed splenic rupture. Given the limited number of patients in their review, however, a relationship between the two entities cannot be ruled out.
Fig. 2. Second CT scan of abdomen performed approximately 13 hours after inital study. Note 2 × 3 cm defect in spleen (curved arrow).
Fig. 3. Third CT scan of abdomen obtained on hospital day 19. Note large contained subcapsular splenic hematoma (large arrows) in continuity with intraparenchymal defect noted on previous scan (curved arrow).
Delayed splenic hematoma is a clinical entity, the true incidence of which is unknown, and the relationship to delayed splenic rupture is unclear. It therefore seems prudent to view changes in the splenic parenchyma on serial CT scans as temporal images of an injury in evolution. REFERENCES 1. Kluger Y, Paul DB, Raves JJ, et al. Delayed rupture of the spleen: myths, facts, and their importance—case reports and literature review. J Trauma 1994;36:568-71. 2. Taylor CR, Rosenfield AT. Limitations of computed tomography in recognition of delayed splenic rupture. J Comput Assist Tomogr 1984;8:1205-7. 3. Fagelman D, Hertz MA, Ross AS. Delayed development of subcapsular hematoma: CT evaluation. J Comput Assist Tomogr 1985;9:815-6. 4. Pappas D, Mirvis SE, Crepps JT. Splenic trauma: false-negative CT diagnosis in cases of delayed rupture. AJR Am J Roentgenol 1987;149:727-8. 5. Farhat GA, Abdu RA, Vanek VW. Delayed splenic rupture: real or imaginary? Am Surg 1992;58:340-5. 6. Black JJ, Sinow RM, Wilson SE, Williams RA. Subcapsular hematoma as a predictor of delayed splenic rupture. Am Surg 1992;58:732-5.