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Bowers WB, Umbu LK, Contreras M, Phillips JK. A Case of Spontaneous Splenic Rupture After a Hemicolectomy on Anticoagulation. Cureus 2024; 16:e67512. [PMID: 39310637 PMCID: PMC11416140 DOI: 10.7759/cureus.67512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2024] [Indexed: 09/25/2024] Open
Abstract
Spontaneous or atraumatic splenic rupture (ASR) is a rare but life-threatening condition that requires swift recognition and intervention. We report the case of a 66-year-old female with a history of hypothyroidism, appendiceal goblet cell adenocarcinoma, and new-onset atrial fibrillation (Afib) requiring anticoagulation. She initially presented with right upper quadrant abdominal pain. She had previously undergone an appendectomy followed by a right hemicolectomy to achieve clear surgical margins after the appendiceal carcinoma diagnosis. In the post-anesthesia care unit, she developed Afib and was started on therapeutic anticoagulation. Cardiac catheterization later revealed three-vessel coronary artery disease, prompting a transition from heparin to apixaban. Three days later, the patient suddenly experienced left shoulder pain and was found to be diaphoretic and hypotensive. Three days post-catheterization, the patient developed sudden left shoulder pain, along with diaphoresis and hypotension. An initial concern for post-catheterization myocardial infarction was ruled out. A subsequent CT of the abdomen and pelvis revealed a large splenic hematoma with rupture and hemoperitoneum, necessitating emergent open splenectomy. Post-operatively, the patient required intensive care monitoring and transfusion support before being discharged to a long-term acute care facility. ASR is typically associated with identifiable pathological conditions; however, this case highlights the complexity of multifactorial etiologies. It emphasizes the need to consider ASR in patients presenting with sudden left shoulder pain and hemodynamic instability, particularly when anticoagulation therapy or recent abdominal surgery are factors. This case underscores the importance of a high index of suspicion and timely intervention to prevent fatal outcomes. Further research is warranted to explore the relationship between anticoagulation therapy and ASR.
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Affiliation(s)
| | - Landry K Umbu
- General Surgery, Western Reserve Health Education, Warren, USA
| | - Megan Contreras
- General Surgery, American University of Antigua, Coolidge, ATG
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Porzionato A, Macchi V, De Caro R. Forensic clinical anatomy of the spleen in medical malpractice. Forensic Sci Int 2019; 304:109772. [PMID: 31601437 DOI: 10.1016/j.forsciint.2019.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/15/2019] [Accepted: 04/24/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Andrea Porzionato
- Section of Human Anatomy, Department of Neuroscience, University of Padova, Padova, Italy
| | - Veronica Macchi
- Section of Human Anatomy, Department of Neuroscience, University of Padova, Padova, Italy
| | - Raffaele De Caro
- Section of Human Anatomy, Department of Neuroscience, University of Padova, Padova, Italy.
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Feola A, Niola M, Conti A, Delbon P, Graziano V, Paternoster M, Pietra BD. Iatrogenic splenic injury: review of the literature and medico-legal issues. Open Med (Wars) 2016; 11:307-315. [PMID: 28352813 PMCID: PMC5329846 DOI: 10.1515/med-2016-0059] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 06/27/2016] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Iatrogenic splenic injury is a recognized complication in abdominal surgery. The aim of this paper is to understand the medico-legal issues of iatrogenic splenic injuries. We performed a literature review on PubMed and Scopus using iatrogenic splenic or spleen injury and iatrogenic splenic rupture as keywords. Iatrogenic splenic injury cases were identified. Most cases were related to colonoscopy, but we also identified cases related to upper gastrointestinal procedures, colonic surgery, ERCP, left nephrectomy and/or adrenalectomy, percutaneous nephrolithotomy, vascular operations involving the abdominal aorta, gynecological operation, left lung biopsy, chest drain, very rarely spinal surgery and even cardiopulmonary resuscitation. There are several surgical procedures that can lead to a splenic injury. However, from a medico-legal point of view, it is important to assess whether the cause can be attributed to a technical error of the operator rather than being an unpredictable and unpreventable complication. It is important for the medico-legal expert to have great knowledge on iatrogenic splenic injuries because it is important to evaluate every step of the first procedure performed, how a splenic injury is produced, and whether the correct treatment for the splenic injury was administered in a judgment.
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Affiliation(s)
- Alessandro Feola
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - Massimo Niola
- Department of Advanced Biome-dical Sciences, University of Naples “Federico II”, Naples, Italy
| | - Adelaide Conti
- Department of Surgery, Radiology and Public Health, Public Health and Humanities Section, University of Brescia - Centre of Bioethics Research, Italy
| | - Paola Delbon
- Department of Surgery, Radiology and Public Health, Public Health and Humanities Section, University of Brescia - Centre of Bioethics Research, Italy
| | - Vincenzo Graziano
- Department of Advanced Biome-dical Sciences, University of Naples “Federico II”, Naples, Italy
| | | | - Bruno Della Pietra
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
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Elessawy M, Schollmeyer T, Rajabi A, Wedel T, Mettler L, Jonat W, Alkatout I. Intraoperative splenic injury as a complication of the laparoscopic excision of uterine myoma. ASIAN PACIFIC JOURNAL OF REPRODUCTION 2012. [DOI: 10.1016/s2305-0500(13)60102-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Aubrey-Bassler FK, Sowers N. 613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review. BMC Emerg Med 2012; 12:11. [PMID: 22889306 PMCID: PMC3532171 DOI: 10.1186/1471-227x-12-11] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 07/28/2012] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Rupture of the spleen in the absence of trauma or previously diagnosed disease is largely ignored in the emergency literature and is often not documented as such in journals from other fields. We have conducted a systematic review of the literature to highlight the surprisingly frequent occurrence of this phenomenon and to document the diversity of diseases that can present in this fashion. METHODS Systematic review of English and French language publications catalogued in Pubmed, Embase and CINAHL between 1950 and 2011. RESULTS We found 613 cases of splenic rupture meeting the criteria above, 327 of which occurred as the presenting complaint of an underlying disease and 112 of which occurred following a medical procedure. Rupture appeared to occur spontaneously in histologically normal (but not necessarily normal size) spleens in 35 cases and after minor trauma in 23 cases. Medications were implicated in 47 cases, a splenic or adjacent anatomical abnormality in 31 cases and pregnancy or its complications in 38 cases. The most common associated diseases were infectious (n = 143), haematologic (n = 84) and non-haematologic neoplasms (n = 48). Amyloidosis (n = 24), internal trauma such as cough or vomiting (n = 17) and rheumatologic diseases (n = 10) are less frequently reported. Colonoscopy (n = 87) was the procedure reported most frequently as a cause of rupture. The anatomic abnormalities associated with rupture include splenic cysts (n = 6), infarction (n = 6) and hamartomata (n = 5). Medications associated with rupture include anticoagulants (n = 21), thrombolytics (n = 13) and recombinant G-CSF (n = 10). Other causes or associations reported very infrequently include other endoscopy, pulmonary, cardiac or abdominal surgery, hysterectomy, peliosis, empyema, remote pancreato-renal transplant, thrombosed splenic vein, hemangiomata, pancreatic pseudocysts, splenic artery aneurysm, cholesterol embolism, splenic granuloma, congenital diaphragmatic hernia, rib exostosis, pancreatitis, Gaucher's disease, Wilson's disease, pheochromocytoma, afibrinogenemia and ruptured ectopic pregnancy. CONCLUSIONS Emergency physicians should be attuned to the fact that rupture of the spleen can occur in the absence of major trauma or previously diagnosed splenic disease. The occurrence of such a rupture is likely to be the manifesting complaint of an underlying disease. Furthermore, colonoscopy should be more widely documented as a cause of splenic rupture.
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Affiliation(s)
- F Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Memorial University of Newfoundland, Health Sciences Centre, St. John’s, Newfoundland and Labrador, St Johns, Canada
- Discipline of Emergency Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland and Labrador, St Johns, Canada
- Discipline of Family Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland and Labrador, St Johns, Canada
| | - Nicholas Sowers
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
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Renzulli P, Hostettler A, Schoepfer AM, Gloor B, Candinas D. Systematic review of atraumatic splenic rupture. Br J Surg 2009; 96:1114-21. [PMID: 19787754 DOI: 10.1002/bjs.6737] [Citation(s) in RCA: 212] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Atraumatic splenic rupture (ASR) is an ill defined clinicopathological entity. METHODS The aim was to characterize aetiological and risk factors for ASR-related mortality in order to aid disease classification and treatment. A systematic literature review (1980-2008) was undertaken and logistic regression analysis employed. RESULTS Some 632 publications reporting 845 patients were identified. The spleen was normal in 7.0 per cent (atraumatic-idiopathic rupture). One, two or three aetiological factors were found in 84.1, 8.2 and 0.7 per cent respectively (atraumatic-pathological rupture). Six major aetiological groups were defined: neoplastic (30.3 per cent), infectious (27.3 per cent), inflammatory, non-infectious (20.0 per cent), drug- and treatment-related (9.2 per cent) and mechanical (6.8 per cent) disorders, and normal spleen (6.4 per cent). Treatment comprised total splenectomy (84.1 per cent), organ-preserving surgery (1.2 per cent) or conservative measures (14.7 per cent). The ASR-related mortality rate was 12.2 per cent. Splenomegaly (P = 0.040), age above 40 years (P = 0.007) and neoplastic disorders (P = 0.008) were associated with increased ASR-related mortality on multivariable analysis. CONCLUSION The condition can be classified simply into atraumatic-idiopathic (7.0 per cent) and atraumatic-pathological (93.0 per cent) splenic rupture. Splenomegaly, advanced age and neoplastic disorders are associated with increased ASR-related mortality.
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Affiliation(s)
- P Renzulli
- Department of Visceral Surgery and Medicine, Inselspital, Berne University Hospital, and University of Berne, Berne, Switzerland.
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Yang D, Zhang D, Guo X, Gong X, Fei X. A multi-dimensional approach for describing internal bleeding in an artery: implications for Doppler ultrasound guiding HIFU hemostasis. Phys Med Biol 2008; 53:4983-94. [PMID: 18711252 DOI: 10.1088/0031-9155/53/18/009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Doppler ultrasound has shown promise in detecting and localizing internal bleeding. A mathematical approach was developed to describe the internal bleeding of the injured artery surrounded by tissue. This approach consisted of a two-dimensional (2D) model describing the injured vessel and a one-dimensional model (1D) mimicking the downstream of the vessel system. The validity of this approach was confirmed by both the numerical simulation and in vivo measurement of a normal porcine femoral artery. Furthermore, the artery was injured using a 16-gauge needle to model a penetrating injury. The velocity waveform at the puncture site was modeled and compared with those at the upstream and downstream of the artery. The results demonstrated that there was a significant increase in magnitude and a phase lag for the peak systolic velocity at the injury site. These results were qualitatively in agreement with the in vivo experiment. Flow turbulence indicated by this approach was also observed in a color Doppler image in the form of a checkered color pattern. This approach might be useful for quantitative internal bleeding detection and localization. Also, the phase lag of the peak systolic velocity was indicated to be potential in the application of internal bleeding detection.
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Affiliation(s)
- Di Yang
- Institute of Acoustics, Key Laboratory of Modern Acoustics (Nanjing University), Ministry of Education, Nanjing University, Nanjing 210093, People's Republic of China
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Lai MC, Chang SJ, Chiang IN, Huang CY. Delayed presentation of splenic laceration due to remote trauma in laparoscopic surgery. J Endourol 2008; 22:705-8. [PMID: 18366317 DOI: 10.1089/end.2007.0280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Splenic laceration is a recognized complication of both open and laparoscopic renal and adrenal surgery. Most injuries reported occur intraoperatively via the transperitoneal approach and require immediate management. Herein we report a patient with a delayed presentation of splenic laceration 17 days after undergoing retroperitoneal hand-assisted laparoscopic nephroureterectomy. Emergent splenectomy was performed and the postoperative course was uneventful. To our knowledge, there has not been a similar case reported before. Because laparoscopic renal surgery is becoming the gold standard of treatment, urologists must be aware of the possibility of splenic laceration during this type of surgery.
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Affiliation(s)
- Ming-Chih Lai
- Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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Gmeiner M, Pfeifer J. Management of complications in surgery of the colon. Eur Surg 2007; 39:15-32. [PMID: 32288768 PMCID: PMC7102154 DOI: 10.1007/s10353-007-0311-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Accepted: 01/23/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND General surgeons are frequently confronted with colorectal diseases in their daily practice, whereby colorectal cancer is the second most common malignant tumour, with almost 5000 new cases every year in Austria. The incidence of benign colon disorders requiring surgery (e.g. colon polyps, sigmoid diverticulitis) is also increasing. The first aim in colon surgery should be to avoid complications and if they occur to treat them properly. METHODS We basically distinguish between general and special complications. As general complications, prevention of malnutrition and support of the immune system should receive special attention. As the number of elderly patients increases, so does the risk not only of thrombembolic complications but also of critical cardiocirculatory situations, and renal and hepatic failure. Special complications depend either on the type of surgery (laparoscopic assisted, conventional open surgery) or the techniques employed (stapled, hand sutured). Handling of the tissue also plays a major role (e.g. dry versus wet pads). RESULTS Shortening of the postoperative stay decreases both hospital costs and the incidence of infections, meaning that minimally invasive surgery and postoperative "fast track nutrition" should be promoted. Emergency operations should be avoided (e.g. bridging through colonic stents), as morbidity and mortality are clearly increased in comparison to (semi-) elective operations. During the operation itself, new equipment and techniques (such as Ultracision®, Ligasure®) as well as a well coordinated team help to reduce complications and duration of surgery. CONCLUSIONS To avoid is better than to repair. If complications do occur, appropriate surgical and intensive - care measures should be taken immediately.
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Affiliation(s)
- M. Gmeiner
- />Department of Pulmology, General Hospital Graz-West, Graz, Austria
| | - J. Pfeifer
- />Department of General Surgery, Medical University of Graz, Graz, Austria
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Luo W, Zderic V, Carter S, Crum L, Vaezy S. Detection of bleeding in injured femoral arteries with contrast-enhanced sonography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2006; 25:1169-77. [PMID: 16929018 DOI: 10.7863/jum.2006.25.9.1169] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVE The purpose of this study was to investigate the feasibility of detecting acute arterial bleeding by means of contrast-enhanced sonography. METHODS Puncture injury was produced transcutaneously with an 18-gauge needle in 26 femoral arteries (13 in the control group and 13 in the contrast-enhanced group) of rabbits. A sonographic contrast agent (Optison; Mallinckrodt Inc, St Louis, MO) was administered intravenously at a dose of 0.06 to 0.07 mL/kg. Sonography of the femoral arteries was performed before and after injury, both before and after injection of Optison, with B-mode imaging, color Doppler imaging, and pulse inversion harmonic imaging (PIHI). RESULTS The specific location of active bleeding could not be visualized in B-mode and PIHI scans in the control group (no Optison injection). After administration of Optison, the bleeding site was visualized because of the increased echogenicity of the extravasated blood at the puncture site in both B-mode imaging and PIHI. In color Doppler images, bleeding sites were localized successfully in 84.6% of the cases in the presence of Optison and in 30.8% of the cases without Optison. Histologic examination (light microscopy) of the hematoma confirmed the presence of contrast agent microbubbles in the extravascular space surrounding the artery. CONCLUSIONS Contrast-enhanced sonography may provide an effective method for detecting arterial bleeding.
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Affiliation(s)
- Wenbo Luo
- Department of Bioengineering, University of Washington, Box 355061, Seattle, 98195, USA.
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