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Clinical case: Splenic artery rupture: want to learn more about it?

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Clinical case: Splenic artery rupture

In this article, we describe a clinical case of a woman who developed a splenic artery rupture. What you would also find interesting is that  the patient suffers from multiple conditions - acute pancreatitis and pleural effusion - which breaks the student's myth that one patient can have only one disease which explains all the symptoms. 

You will find the presentation of these diseases, their managment and important anatomical considerations.

Key Facts
Acute pancreatitis Inflammation of the pancreas caused by the obstruction of common bile ducts or alcohol abuse
Biliary lithiasis Presence of the gallstones within the biliary ducts. The gallstones obstruct the release of pancreatic enzymes into the duodenum, causing the enzymes to activate within the pancreatic tissue which can cause the digestion of the pancreas, resulting with pancreatitis
Pleural effusion Presence of fluid in the pleural cavity. Depending on the type of fluid, it can be hydrothorax (serous fluid), hemothorax (blood), chylothorax (lymph) and pyothorax (pus).
Pancreatic pseudocyst Cystic lesion that is lined with the fibrous tissue rather than epithelial or endothelial cells as it is in the true cyst.
Intraperitoneal organ Organ that is on all surfaces surrounded by peritoneum
Splenectomy Method of choice after injuries of the spleen. Suturing of the spleen is not recommended since the tssue is very friable, and the hematopietic functions of the spleen are replicated in the bone marrow.

After reviewing this case you should be able to describe the following:

  • The medical relationship between alcoholism and pancreatitis.
  • Why the patient underwent a cholecystectomy.
  • Explain anatomically what a pleural effusion is and how it would be recognized in a standard PA chest radiograph. What is the likely relationship between the pancreatic pseudocysts and the pleural effusion.
  • How a pseudocyst differs from a true cyst.
  • How does intraperitoneum differ from retroperitoneum?
  • Why splenectomy is preferred rather than surgical repair of the spleen.

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.

Case description

A 58-year-old woman had a history of acute pancreatitis, chronic alcoholism and left pleural effusion in the last 12 months. Due to the abdominal pain, the patient underwent an abdominal ultrasound and CT scan. These scans revealed biliary lithiasis (gallstones) and the presence of three large cystic masses in her pancreas and spleen, as well as the pleural effusion (Figures 1-4). The patient declined surgical intervention at the time.

Figure 1. Dissection image showing normal anatomy pertinent to this case.

After reviewing the dissection image of the normal anatomy within the region of interest, let's see how it should look like at the axial CT scan in order to be prepared to recognize any form of pathological presentation.

Figure 2. Axial CT showing normal anatomy of the region of interest for this case. Notice how both the splenic vein and artery are intimately related to the pancreas.

After getting familiar with the normal axial CT, it is very easy to detect both pancreatic and splenic pseudocysts shown at the patient's axial CT scans (Figures 3&4).

Figure 3. Axial CT scans showing the pancreatic and splenic pseudocysts (highlighted with green).

Ultimately, the coronal CT scan of the patient's abdomen provides a good look at the pseudocysts and enables a complete estimation of its size and severity.

Figure 4. Coronal CT images showing the pseudocysts (highlighted with green) and the pleural effusion in the left pleural cavity (PE).

Subsequently, the patient was admitted to the hospital for intense abdominal pain with altered general status (blood pressure 90/60, pulse 110) and a drop of the hemoglobin level to 8.2g/dL. An abdominal CT exam conducted in the emergency setting showed the same cystic lesions as found previously and also suggested the presence of a ruptured splenic artery pseudoaneurysm, and splenic hematoma. Due to the clear signs of significant hemorrhage, an emergency laparotomy was performed.

Management

During the surgical procedure, a small amount of intraperitoneal blood was found as was a pancreatic pseudocyst filled with clotted and fresh blood. This pseudocyst extended to the spleen and corresponded to the three cystic masses identified on the preoperative CT scan (Figures 3&4). The splenic artery was causing pulsatile bleeding into the cyst cavity. Attempted anatomic dissection of the splenic vessels at the upper pancreatic border (Figures 1&2) was not successful because of fibrosis and adhesions. Instead, the spleen was removed, and a partial cystectomy (removal of cysts) with ligation of the splenic artery was performed at the location of the hemorrhage, as was cholecystectomy due to cholelithiasis.

Complications and evolution

There were two postoperative complications in this patient: an elevated level of platelets, which required prolonged anticoagulation therapy (low molecular weight heparin followed by oral warfarin treatment); and, a pancreatic fistula with a 100–200 mL/day output. The fistula closed without intervention five months after surgery. At a two-year follow up exam, the patients had no complaints.

Anatomical considerations

The key anatomical relationship, in this case, is the relationship of the splenic artery to the pancreas. The splenic artery arises from the celiac trunk and passes to the left running along the upper border of the pancreas and often partially embedded in the upper pancreas (Figure 5). As it traverses along the upper border of the pancreas the splenic artery sends many branches into the body of the pancreas. (The splenic vein also has an intimate relationship to the pancreas.

Figure 5. Pancreas in situ (overview)

We were able to conclusively label the splenic vein and the splenic artery in Figure 2 only because we were able to follow these structures in additional CT scans in this patient. Based solely on this single CT scan it would be impossible to differentiate splenic artery from vein, and incidentally, based on the cadaver image shown in Figure 1, the labeling in the CT would likely be reversed. But both of these vessels typically meander superior or slightly posterior to the pancreas, and one cannot generalize about the amount of undulation from one person to another).

Clinical case: Splenic artery rupture: want to learn more about it?

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