SPLEEN RUPTURE - IN A CASE WITH CHRONIC PANCREATITIS

SPLEEN RUPTURE : IN A CASE WITH CHRONIC PANCREATITIS 脾臟破裂 : 發生於慢性胰臟炎患者 澄清醫院 內科部胃腸肝膽科 黃俊彥 黃一修 葉俊麟 黃仁杰 黃裕庭辛政憲 何士奇 趙哲仁 CASE PRESENTATION  30 Y/O male patient  CC : severe LUQ abdominal pain for two days.  PH : Chronic pancreatitis. Chronic B hepatitis. Alcoholism : 高梁酒 half bottle QD. Smoking 1 PPD for 10 years. No operation history. Denied other major systemic disease. PHYSICAL EXAMINATION(I)  General apperance : acute ill looking.  BH : 167.5cm BW :58 kg.  Vital sign : 36.4/92/18 BP:116/68 mmHg.  HEENT : conjunctiva not pale, sclera not icteric  Neck : supple, LAP(-), JVE (-). PHYSICAL EXAMINATION(II)  Chest : symmetric expansion. clear breathing sound, regular heart sound, no moumur.  Abdomen : soft and flat. hyperactive bowel sound. left LUQ abdominal tenderness with radiation to left flank, no bruise.  Extremity : freely movable. LABORATORY DATA(I) Glu 105, AST 51, ALT 52, BIL (T) 0.6, BUN 8, CR 0.9, Na 138, K 3.2, Amylase 213, Lipase 222, CRP 8.1 WBC 14700(neu 62.8%, lym 27%, mono 9.2%, eos 0.15%), Hb 17.3, Hct 51.6, PLT 171,000/ul LABORATORY DATA(II) 12-1 Amylase 178, Lipase 207. 12-12 Amylase 151, Lipase 102. 12-22 Amylase 96, Lipase 64. CLINICAL COURSE (I)  Admitted via ER because of severe LUQ abdominal pain for 2 days. Diarrhea and cramping abdominal pain were noted too. No symptoms such as fever, vomit or tarry stool passage. CLINICAL COURSE (II)  Spleen abscess was suspected after abdominal echo study. Abdominal CT found chronic pancreatitis with pseudocyst formation in pancreatic tail nearing splenic hilum and spleen abscess(5x4cm2) in inferior portion of spleen, post traumatic injury change was suspected. CLINICAL COURSE (III)  Under the impression of spleen abscess. Pig tail drainage was done. Severe abdominal pain with hypotension and high fever developed suddenly 3 weeks later, follow-up abdominal echo and CT scan all suspect spleen rupture. CLINICAL COURSE (IV)  Emergent operation was done and p’t discharged smoothly 1 week later . SPLEEN RUPTURE Injury to the spleen, causing it to rupture. Bleeding of a rupture spleen can be fatal. The spleen is vulnerable to injury, particularly if it is enlarged due to any underlying disorders(infectious mononucleosis is the most common). Spleen injuries are infrequent in athletes but when they do occur, they can be disastrous. SINGS AND SYMPTOMS Recent injury to the LUQ or LT rib fracture. Vomiting. LUQ abdominal pain or tenderness. Pain in the left shoulder or left side of the neck. Rapid heart rate, low blood pressure. Other signs of shock:pale, moist and sweaty skin, anxiety with feelings of impending doom, SOB and rapid breathing, disorientation and confusion. CAUSES Direct injury to the left upper abdomen or left side of the chest. Spontaneous rupture of the spleen is well described in many diseases, malaria is the most common, others include infectious mononucleosis, splenic neoplasms and hematological malignancies. A rare subtype of spontaneous rupture of a normal spleen occurring after severe vomiting or coughing. RISK INCREASES WITH Contact sports. Bleeding disorders such as hemophilia. Infectious mononucleosis or any other illness that causes spleen enlargement. HOW TO PREVENT Avoid caused and risk factors when possible. Don’t return to athletic activities until a spleen enlarged by disease has return to normal. Infectious mononucleosis or any other illness that causes spleen enlargement. DIAGNOSTIC MEASURES Before surgery: Blood and urine studies. X-rays of the abdomen and chest. After surgery: Examination of all removed tissue Additional blood studies. MANAGEMEN Resuscitation the shock patient with large amount intravenous fluids and blood transfusions. Emergent operation to remove the ruptured spleen. POSSIBLE COMPLICATIONS(I) At the time of injury: Rapid deterioration due to internal bleeding, possibly leading to death. POSSIBLE COMPLICATIONS(II) Following surgery: Excessive bleeding. Infection. Incisional hernia. Lung collapse. Inflammation of the pancreas. Deep-vein blood clots. Pneumonia. PROBABLE OUTCOME Expect complete healing if no complications occur. Allow about 4 week for recovery from surgery. CONCLUSION In patient receives any abdominal injury, especially direct injury to the left upper abdomen or left side of the chest, if the symptoms last longer than a few minutes, worsen or recur within hours or days, spleen rupture should be considered. Resuscitation the shock patient and emergent operation to remove the injured spleen is necessary.