Unexpected Delayed Rupture of the Spleen That Initially Appeared Normal on Computed Tomography

Article information

Trauma Image Proced. 2019;4(1):19-21
Publication date (electronic) : 2019 May 31
doi : https://doi.org/10.24184/tip.2019.4.1.19
1Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Trauma center
2Department of Neurosurgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Trauma center
Correspondence to: Pil Young Jung,, Department of Surgery, Yonsei university Wonju college of medicine, Wonju Severance Christian Hospital, Trauma center, 220-701, 20 Ilsan-ro, Wonju-si, Gangwon-do, South Korea Tel: 82-33-741-0882, Fax: 82-33-741-0574, E-mail: surgery4trauma@yonsei.ac.kr
Received 2019 March 3; Revised 2019 May 16; Accepted 2019 May 16.

Abstract

Only a few cases of delayed rupture of the normal spleen in association with trauma have been reported. We describe the case of a 47-year-old man who exhibited no evidence of rupture and an apparently normal spleen who presented with a delayed rupture and hemoperitoneum 4 days after a traffic accident.

CASE

A 47-year-old man had been a passenger in a traffic accident, and he was found outside the car when he was rescued. On arrival to our trauma center, although he was intoxicated, he had a Glasgow Coma Scale score of 15, was neurologically intact, and complained only of a headache. In the emergency room, computed tomographic (CT) scans of the brain, neck, chest (with contrast material), and abdomen and pelvis (with contrast material) were obtained. Imaging findings included an acute subdural hemorrhage with scalp laceration. No other acute findings were seen on the initial abdomenpelvis contrast-enhanced image. The official reading of the CT scan by the radiologist was also normal (Fig. 1.). The patient was admitted to general ward for nonoperative management. Four days after hospitalization, the patient’s hemoglobin level dropped abruptly from 17.0 to 9.9 g/dL. A second abdomen-pelvis CT scan with contrast material revealed a grade IV splenic rupture with hemoperitoneum (Fig. 2.). The patient was taken to the operating room for emergency explorative laparotomy, and splenectomy was performed (Fig. 3.). Eleven days after admission, the patient was discharged home.

Fig. 1.

Initial computed tomographic scan, showing no splenic injury.

Fig. 2.

Follow-up computed tomographic scan, showing splenic hemorrhage with hemoperitoneum.

Fig. 3.

Specimen (spleen).

DISCUSSION

A majority of patients with spleen trauma have acute injuries, but up to 15% present with a delayed rupture after a substantial abdominal injury [1]. Delayed rupture of the spleen in cases of trauma, which is unusual, has been reported to occur 4 to 8 days after injury [2]. The rate of mortality from delayed splenic rupture is significantly higher (5% to 15%) than that of mortality from total acute splenic injuries (1%) [3]. Although there is no predictor for a splenic injury, the risk of delayed splenic rupture should always be considered when patients are managed nonoperatively. We suggest that delayed spleen injury be considered part of the differential diagnosis in patients presenting with hemodynamic instability late after trauma, even when the spleen appears normal on the initial CT scan.

Notes

Conflicts of Interest Statement

None of authors have a conflict of interest.

References

1. Sowers N, Aubrey-Bassler FK. Trivial trauma and delayed rupture of a normal spleen: a case report. J Med Case Rep 2011;5:591.
2. Hamidian Jahromi A, Migliaro M, Romano M, Sangster G. Delayed Splenic Rupture; Normal Appearing Spleen on the Initial Multidetector Computed Tomography (MDCT) Can Sometimes Be Misleading. Trauma Mon 2016;21(5)e24465.
3. Kodikara S. Death due to hemorrhagic shock after delayed rupture of spleen: a rare phenomenon. Am J Forensic Med Pathol 2009;30(4):382–3.

Article information Continued

Fig. 1.

Initial computed tomographic scan, showing no splenic injury.

Fig. 2.

Follow-up computed tomographic scan, showing splenic hemorrhage with hemoperitoneum.

Fig. 3.

Specimen (spleen).