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

Jae Sik Chung; Jong Wook Choi; Pil Young Jung

doi:10.24184/tip.2019.4.1.19

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.

Key Words: Splenic rupture, Hemoperitoneum

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.

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.