[Surgical abstention in closed injuries of the spleen]

A Huge Subcapsular Splenic Cyst Like Hematoma in Sickle Cell Anemia

Nontraumatic splenic rupture and hematoma are rare in sickle cell disease. We present a case of a 22-year-old Saudi male with sickle cell disease. He presented to our hospital with a history of nontraumatic abdominal pain, hemodynamic instability, and abdominal tenderness, with a large mass extending to the umbilicus. A computed tomography (CT) examination showed splenomegaly and a spleen infarction. The patient was admitted to the intensive care unit (ICU) and stabilized. He was transferred to the regular ward and discharged against medical advice (DAMA). Later on, he presented again with persistent abdominal pain. He underwent splenectomy with cholecystectomy. The patient did well postoperatively and was discharged in good condition. While conservative management is common, operative management should be considered in patient with persistent pain. Splenic rupture has a high mortality rate.

Pathological rupture of the spleen in malaria: analysis of 55 cases (1958-2008)

BACKGROUND

Splenic rupture during acute malaria is rare but underreported. Because splenic rupture occurs mostly in non-immune adults, ongoing malaria elimination efforts may paradoxically increase the proportion of Plasmodium-infected patients suffering from this life-threatening complication. The pathogenesis and optimal patient management are still debated.

METHOD

We collected and analysed reports of pathological rupture of the spleen associated with malaria published over the last 50 years in five languages.

RESULTS

Fifty-five cases were reported, due to Plasmodium falciparum (n=26), Plasmodium vivax (n=23), Plasmodium ovale (n=2), Plasmodium malariae (n=2), or P. vivax-falciparum (n=2), and occurred in travellers (n=24), locals (n=21), expatriates (n=6) or migrants (n=4). Median age was 31.5 years and sex ratio M/F 3.2. Splenic rupture was complete with hemoperitoneum (n=50), or partial (n=5). Death occurred in 12 patients (22%), 8 of whom from early irreversible collapse (n=7) or unexpected death (n=1). Death rate was higher among travellers than in other patients (9/24, 38%, versus 3/31, 10%, p=0.01). Clinical features of P. falciparum- or P. vivax-associated splenic rupture were strikingly similar. Treatment included in-hospital medical observation without surgery (conservative management, n=14), immediate splenectomy (n=29), delayed splenectomy (n=4), or none (patients dying at admission, n=8). The type of treatment, conservative or not, had no influence on prognosis. The median duration of malaria symptoms before diagnosis was longer in our review (5-6 days) than in previous reports on imported malaria (3-4 days), suggesting that early diagnosis and therapy of malaria may reduce the incidence of splenic rupture.

CONCLUSIONS

Abdominal pain, collapse, or fainting is warning symptoms. Fourteen published observations support conservative management in carefully selected patients. Spleen preservation likely reduces the risk of future severe malaria attacks in patients with potential further exposition to Plasmodium sp., and also that of overwhelming sepsis in all.

[Non operative management of blunt splenic trauma in adults]

Nonoperative management of blunt splenic injury allows preservation of the immune function of the spleen while avoiding unnecessary laparotomy. The aim of our study was to evaluate the feasibility and the results of conservative management of adult blunt splenic trauma in the context of a developing country. Nonoperative management was proposed for 52 out of 62 patients with blunt splenic trauma treated at the Casablanca University Hospital, Morocco. Motor vehicle-road accidents (88%) were the most common etiology. Multiple trauma was present in 79% of the cases. 15% of the cases had hemodynamic instability. Ultrasonography was performed in 52 patients; it showed splenic contusion in 45 patients and subcapsular hematoma in 7 patients. CT scan showed splenic contusion in 11 patients. Four cases ultimately required operative management with one death. Of the remaining 48 patients, 45 had an uneventful course with observation, but there were two deaths in the observation group.

Splenic rupture and haemoperitoneum in a patient with non-compaction of the left ventricular myocardium

The anaesthetic and critical care management of blunt abdominal trauma in a patient previously diagnosed with non-compaction of the left ventricular myocardium (a rare autosomal dominant inherited disease) is reported. The management was influenced by the presence of an implanted automated internal defibrillator and treatment with anticoagulants because of the high frequency of severe arrhythmias and systemic embolism. The pathophysiology of ventricular non-compaction is reviewed briefly.