Nancy Panko, MD, Seeyuen Lee, MD, Melissa Boyle, MD, Phillip Leggett, MD. Houston Northwest Medical Center
Introduction: Massive splenic infarction (MSI) due to hypoperfusion is rare, with only one source documenting MSI from hypoperfusion in a patient with septic shock. We report a case of MSI managed with laparoscopic splenectomy three weeks after an exploratory laparotomy performed for control of a bleeding duodenal ulcer.
Case: Patient is a 28 year old man who presented with rectal bleeding. He underwent imaging but then sustained cardiac arrest due to hypovolemia. He responded to resuscitation and vasopressors, and then surgery was consulted for evaluation. We attempted endoscopic management of a bleeding duodenal ulcer with arterial hemorrhage. The ulcer was injected and clipped without success. The patient was then taken emergently for exploratory laparotomy with duodenotomy and ligation of the gastroduodenal artery. A drain was left adjacent to the duodenotomy and feeding jejunostomy was placed. The patient was extubated after definitive abdominal closure on post-operative day two. He received over 30 units of blood products in the first 24 hours.
Post-operatively, the patient had shock liver, acute renal failure requiring hemodialysis, and VTE. He developed fever 10 days postoperatively, and work up was initiated with no significant source. CT of the abdomen and pelvis was performed (Figure 2). The spleen was noted be significantly enlarged without evidence of perfusion. No other abnormalities were noted.
The patient was counseled that splenic infarction was likely the source of his fever. He was initially asymptomatic, but then developed abdominal pain and anorexia. This did not improve with conservative measures and he agreed to surgery.
Patient underwent uneventful laparoscopic splenectomy on postoperative day 24. Pathology showed marked splenic necrosis.
He recovered uneventfully, and was seen in clinic with no additional complaints.
Discussion: MSI is a rare occurrence, with less than twenty documented cases. The majority of these cases occurred secondary to blood disorders or coagulopathies, malignancy, infection, and organ transplant. Only one other case has been reported linking MSI to hypoperfusion and shock. This was attributed to both hypoperfusion as a result of septic shock as well as hypercoaguability related to the inflammatory response.
Splenic preservation is preferred in most cases of splenic injury, to preserve immune function. Splenectomy is reserved for patients with refractory abdominal pain, hemorrhage, abscess, or pseudocyst. In our case, the patient had significant abdominal pain, and requested operative management after a trial of conservative therapy. We were able to perform his splenectomy laparoscopically, which further sped his recovery.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95371
Program Number: P011
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster