Overly Traumatic: A Teenager Elbowed in the Stomach

Overly Traumatic: A Teenager Elbowed in the Stomach

Case: 

A 17 yo healthy M presents with abdominal pain and a syncopal episode several hours after getting elbowed in the stomach at a soccer game.

PMH: Intermittent asthma

ROS: Sore throat, cough and fatigue x 1 week.

Physical Exam:

VS: T 98.3 °F | HR 90 | BP 129/60 | RR 16 | SpO2 100%

Pale but comfortable and alert. Abdomen diffusely tender, guarding in the upper quadrants. Exam otherwise unremarkable.

FAST exam: 

RUQ: Free fluid in Morrison’s pouch & at the tip of the liver

LUQ: Free fluid in splenorenal recess & bowel floating in free fluid

Transverse Bladder: Large amount of fluid & clotted blood anterior to the bladder

Click ahead to reveal diagnosis

Diagnosis:

Infectious mononucleosis with splenic rupture

Abdominal CT: 

Axial CT

Sagittal CT

Splenomegaly with large, complex splenic laceration, active extravasation near splenic hilum (vascular “blush”, red arrows) and large volume of hemoperitoneum

Mono & splenic rupture:

– Splenomegaly is seen in 50-60% of patients with mono

  • peaks between day 4-21 of illness
  • usually recedes by 3rd week

– Rupture seen in 1-2/1000 cases of mono

  • almost exclusively males
  • 50% spontaneous

– Symptoms of splenic rupture: Prodrome of fever, pharyngitis, fatigue, lymphadenopathy for 1-3 wks with:

  • acute onset abdominal pain
  • signs of hypovolemia
  • Kehr sign (referred pain to L shoulder from diaphragmatic irritation, seen in 50%)

– Fatality is extremely rare 

Management of splenic rupture in children:

  • Splenic conservation through non-operative management is preferred in hemodynamically stable children and adolescents. Literature has shown this is safe and effective even in high-grade splenic lacerations and avoids the risks of laparotomy and post-splenectomy sepsis (asplenic children have 1-3% risk of sepsis, with mortality rates up to 50-80%).
  • For isolated splenic injuries:
    • >90%: no surgical intervention necessary
    • <5%: need transfusion
    • 1%: splenectomy
    • Initial non-op management does not increase need for transfusion, length of stay or rates of splenectomy
  •  Food for thought: Since splenic rupture from mono is so rare, outcomes in conservative management in these cases have not been well studied. Some theorize that since the spleen is architecturally altered by infection with mono, it may not heal as well as a healthy spleen that ruptures from trauma. However, many case reports have demonstrated successful non-operative management of splenic rupture from mono (including our patient, read on).

ED management of a child with splenic rupture*:

  • HD unstable —> OR
  • HD stable:
    • Bed rest
    • NPO
    • Serial CBCs (q4-6 hr)
    • Don’t flood with IV fluids
    • Type & cross on hold for higher grade injuries
    • Continuous HD monitoring

*Note, if not at a trauma center, stabilize the patient and transfer to one

Avoiding splenic rupture for patients diagnosed with mono:

No clear consensus on this, but note the following:

  • Just because you don’t feel a big spleen doesn’t mean the patient is safe.
    • When compared to ultrasound, physical exam diagnosis of splenomegaly in patients with mono has poor sensitivity, therefore any child diagnosed with mono, with or without exam finding of splenomegaly, should be cautioned to avoid contact sports in at least the first 3 weeks of illness.
    • Splenic rupture is extremely rare after 4 weeks.
    • Expert opinion cautions anywhere from 3 weeks to 6 weeks
  • Some recommend ultrasound documentation of normal spleen size prior to resuming sports, but this is not a widespread practice, especially since it’s hard to know what an individual child’s normal spleen size would be.
  • You can caution against sports all you want, but remember 50% of splenic rupture from mono is spontaneous, usually from a Valsalva-like maneuver or sudden, minor compression from diaphragmatic or abdominal wall contraction causing internal trauma to an enlarged and fragile spleen. This has reportedly occurred with coughing, sneezing, defecation, sitting up, or turning over in bed!

 

Bottom line: Tell any patient you diagnose with mono to avoid sports and seek medical attention should they experience sudden abdominal pain, lightheadedness or syncope, or left shoulder pain.

 

Our patient’s ED and hospital course:

  • BPs 120s/60-70s with HR 80s-90s after 1 bolus
  • Hgb in ED: 11.1 -> 10
  • AST 72, ALT 69
  • Monospot +, EBV titers +
  • Admitted to PICU:
    • Strict bedrest
    • PCA for pain control
    • Serial CBCs (Hb nadir of 8.9 on HD2; rose to 9.8 on d/c)
    • Discharged home on HD4 with f/u ultrasound & surgery clinic in 6 weeks

 

Author: Almaz Dessie, MD

Editors: Robyn Wing, MD, Chris Merritt, MD MPH & Elizabeth Jacobs, MD

 

References:

Dommerby H, Stangerup SE, Stangerup M, et al.. Hepatosplenomegaly in infectious mononucleosis, assessed by ultrasonic scanning. J Laryngol Otol. 1986; 100: 573–579.

Duron VP, Day KM, et al. Maintaining low transfusion and angioembolization rates in the age of nonoperative management of pediatric blunt splenic injury. Am Surg. 2014;80(11):1159-63.

Rinderknecht AS, Pomerantz WJ. Spontaneous splenic rupture in infectious mononucleosis: case report and review of the literature. Pediatr Emerg Care. 2012;28(12):1377-9.

Stephenson JT, DuBois JJ. Nonoperative management of spontaneous splenic rupture in infectious mononucleosis: a case report and review of the literature. Pediatrics. 2007;120(2):e432-5.

Velanovich V, Tapper D. Decision analysis in children with blunt splenic trauma: the effects of observation, splenorrhaphy, or splenectomy on quality-adjusted life expectancy. J Pediatr Surg. 1993;28:179-185.

 

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