Shinkai Toko, Ono Kentaro, Masumoto Kouji, Urita Yasuhisa, Gotoh Chikashi
Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan.
Surg Case Rep. 2018 Jul 11;4(1):75. doi: 10.1186/s40792-018-0477-5.
Nonoperative management (NOM) has been established as the standard treatment for isolated blunt organ injury in hemodynamically stable pediatric patients. Although delayed splenic rupture or bleeding is a rare complication in NOM, it is an issue that many pediatric surgeons are greatly concerned about. We herein report a rare pediatric case concerning the mechanisms involved in delayed splenic rupture after NOM.
A 9-year-old boy with severe abdominal pain was transferred to our hospital. Twenty-one hours before the admission, he had been kicked in the region of his left lateral abdomen. Contrast-enhanced abdominal computed tomography revealed a severe intra-parenchymal hematoma and multiple lacerations of the spleen with a large amount of hemoperitoneum without active bleeding. His condition was diagnosed as a grade III injury on the AAST splenic injury scale. After fluid resuscitation, his vital signs became stable. The patient was treated with NOM in our intensive care unit. However, suddenly after defecation (72 h after the injury), he started complaining of severe abdominal pain and left shoulder pain. His blood pressure dropped to 70/35 mmHg, and he started to lose consciousness. Abdominal ultrasonography (US) revealed increased ascites. Fluid resuscitation and blood transfusion were performed. His symptoms and abdominal US findings suggested that splenic re-bleeding had caused delayed splenic rupture to occur. Emergency splenectomy was performed. The resected spleen was enlarged with a large parenchymal hematoma. The posterior-lateral side of the splenic capsule was ruptured.
The mechanism of delayed splenic rupture in our case was considered to be the result of a tear in the subcapsular hematoma caused by stretching the splenocolic ligament related to a bowel movement during defecation. Although delayed splenic rupture or bleeding is unpredictable, it is very important to understand the mechanisms and to educate the family of the children with splenic injuries of the warning signs of delayed rupture or bleeding.
非手术治疗（NOM）已被确立为血流动力学稳定的小儿患者孤立性钝性器官损伤的标准治疗方法。尽管延迟性脾破裂或出血在非手术治疗中是一种罕见的并发症，但这是许多小儿外科医生极为关注的问题。我们在此报告一例罕见的小儿病例，涉及非手术治疗后延迟性脾破裂的相关机制。
一名9岁严重腹痛男孩被转诊至我院。入院前21小时，他左侧腹部被踢。腹部增强计算机断层扫描显示脾实质内有严重血肿，脾脏多处裂伤，伴有大量腹腔积血但无活动性出血。根据美国创伤外科学会（AAST）脾损伤分级标准，其病情被诊断为Ⅲ级损伤。液体复苏后，他的生命体征稳定。该患者在我们的重症监护病房接受非手术治疗。然而，在受伤72小时后排便时，他突然开始诉说严重腹痛和左肩疼痛。他的血压降至70/35 mmHg，开始失去意识。腹部超声检查（US）显示腹水增加。进行了液体复苏和输血。他的症状和腹部超声检查结果提示脾再次出血导致了延迟性脾破裂。遂进行了急诊脾切除术。切除的脾脏肿大，有巨大的实质内血肿。脾包膜后侧破裂。
我们病例中延迟性脾破裂的机制被认为是排便时与肠蠕动相关的脾结肠韧带拉伸导致包膜下血肿撕裂的结果。尽管延迟性脾破裂或出血不可预测，但了解其机制并对脾损伤患儿的家属进行延迟性破裂或出血警示征象的教育非常重要。
