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Quick Consult: Symptoms Syncope, Upper Abdominal Pain

Wiler, Jennifer L. MD, MBA

doi: 10.1097/01.EEM.0000456988.36475.6b
Quick Consult

Dr. Wileris an associate professor of emergency medicine and the vice chair of the department of emergency medicine at the University of Colorado School of Medicine. Read her past columns athttp://bit.ly/WilerConsult.

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A 21-year-old man presents with multiple syncopal events and mild upper abdominal pain radiating to his chest after lifting a heavy box at work the day before. He has no previous medical history, recent illness, shortness of breath, lower extremity swelling, nausea/vomiting, fever, or bloody stools.

This is what you see on CT. What is the diagnosis, and how would you manage this condition?

The spleen is the most commonly injured solid organ, and injuries can result in life-threatening hemorrhage if not promptly recognized and treated. The spleen has two major functions. As the largest lymph organ (approximately 25% of all lymphatic tissue in the body), the spleen produces lymphocytes and phagocytes to fight infectious pathogens. The spleen is also responsible for blood filtration and metabolizing defective blood cells. It is not necessary for survival despite these important functions because the liver can take over some of these duties if necessary.

The spleen resides under the diaphragm, lateral to the stomach in the left upper quadrant of the abdomen, protected by the ribs. Injury to the spleen is most commonly related to blunt force trauma from a motor vehicle collision, fall, assault, or sports. Iatrogenic injury related to endoscopic or surgical procedures also occurs. (Am Surg 2014;80[4]:E111; Endoscopy 2013;45[Suppl 2]UCTN:E221; Ann Ital Chir 2013 28;84[ePub].) Spontaneous rupture has also been reported. (Int J Rheum Dis 2013;16[5]:606; And J Coll Physicians Surg Pak 2013;23[6]:427.) Patients taking anticoagulants are also at increased risk of rupture.

Patients with splenic ruptures can present in a variety of ways, but that presentation depends primarily on whether the injury is contained within the splenic capsule or if capsule violation and organ rupture occurred. Patients with splenic rupture present with signs of impending or established hemorrhagic shock. Patients with contained splenic “fracture,” however, can have a more cryptogenic presentation, ranging from vague abdominal discomfort to abdominal pain, left chest wall pain, or left shoulder pain, also known as Kehr's sign. Originally described by German surgeon Hans Kehr, this sign is a classic example of referred pain caused by diaphragmatic and phrenic nerve irritation. Patients with a traumatic etiology may also have associated chest trauma including rib features, a seatbelt sign, or flank hematoma.

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Diagnosing a ruptured spleen requires ultrasound and CT scan. A FAST examination should be performed on any patient with suspected intra-abdominal hemorrhage. Patients with an extracapsular ruptured spleen will have a positive FAST exam. Patients with a negative FAST exam but with a concern of a splenic injury should have an abdominal CT scan, preferably with IV contrast. (Radiology 2013;268[1]:79; Semin Roentgenol 2012;47[4]:352.)

The standard grading of splenic injury developed by the American Association for the Surgery of Trauma Organ Injury Scale (OIS) for spleen, liver, and kidney injuries using the National Trauma Data Bank (http://bit.ly/1ysV0rk) is as follows:

The organ injury scale from the American Association for the Surgery of Trauma (http://bit.ly/-1ysV0rk) used the National Trauma Data Bank to grade spleen, liver, and kidney injuries as follows:

  • Grade I: Hematoma: subcapsular, less than 10 percent of surface area. Laceration: capsular tear less than 1 cm in depth into the parenchyma.
  • Grade II: Hematoma: subcapsular, 10 to 50 percent of surface area. Laceration: capsular tear, 1 to 3 cm in depth but not involving a trabecular vessel.
  • Grade III: Hematoma: subcapsular, greater than 50 percent of surface area or expanding, ruptured subcapsular or parenchymal hematoma or intraparenchymal hematoma greater than 5 cm or expanding. Laceration: greater than 3 cm in depth or involving a trabecular vessel.
  • Grade IV: Laceration involving segmental or hilar vessels with major devascularization (i.e., greater than 25 percent of spleen).
  • Grade V: Hematoma: shattered spleen. Laceration: hilar vascular injury which devascularizes spleen.

Treating patients with suspected splenic rupture should follow standard trauma resuscitation protocols, which can include observation, embolization (Am Surg 2014;80[9]:265), or surgical intervention depending on the severity of injury, comorbid conditions, and other injuries. (BMJ 2014;348:g1864; J Trauma Acute Care Surg 2013;74[2]:546.) Nearly 70 percent of cases are managed nonoperatively, and those tend to be patients with Grade I-III injuries. (J Intensive Care Med 2006;21[5]:296; J Trauma Acute Care Surg 2012;72[5]:1127.) A higher failure rate of observation has been noted for higher grade injuries. (J Trauma Acute Care Surg 2013;74[2]:546.)

This patient was diagnosed with a shattered spleen (grade 5 injury) with a large volume of intraperitoneal hemorrhage, mixed high and low density, and a minimally displaced left posterior 11th rib fracture overlying the spleen. The patient had an uneventful hospital course after he was observed for 72 hours.

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Corrections

The wrong EKG appeared in the Spontaneous Circulation column, “Secrets Behind the Curtain,” in the September issue. A corrected version of the article is available at http://bit.ly/1wwCX1J.

The September article, “The Miserable State of Rural Emergency Medicine,” also mislabeled a list of requirements for a rural emergency medicine residency as requisites for a rural ED. The headline on that article was intended to convey the difficulty of attracting emergency physicians to rural practice, and EMN apologizes for the unintended inference. A corrected version of the article is on our website at http://bit.ly/Zq43tu.

© 2014 by Lippincott Williams & Wilkins