Rotura esplénica espontánea secundaria a mononucleosis infecciosa / Spontaneous splenic rupture secondary to infectious mononucleosis

Resumen La rotura esplénica es una complicación rara pero potencialmente fatal de la mononucleosis infecciosa. Presentamos el caso de una mujer de 18 años que consultó por dolor abdominal de siete días de evolución, asociado a fiebre y pérdida de conciencia brusca y transitoria. En el hemograma presentaba una anemia y linfocitosis. Se realizó una tomografía computada de abdomen y pelvis que mostró un extenso hemoperitoneo, con el bazo rodeado por un hematoma, y numerosas adenopatías cervicales, mesentéricas e inguinales. Se efectuó una laparoscopía que demostró abundante hemoperitoneo con coágulos a lo largo de la gotera parietocólica izquierda. El bazo estaba completamente decapsulado y rodeado por una colección hemática con sangrado en napa. Se realizó una esplenectomía total sin complicaciones. El estudio histopatológico esplénico mostró una atenuación de la pulpa blanca y expansión de la pulpa roja con áreas de hemorragia y necrosis. La IgM anti-cápside para virus de Epstein Barr fue positiva. La paciente evolucionó de manera favorable.

Abstract Splenic rupture is a rare but potentially fatal complication of infectious mononucleosis. We report the case of an 18-year-old woman, who presented a 7-day history of abdominal pain, sudden temporary loss of consciousness and fever. Admission blood tests showed anemia, and lymphocytosis. Computed tomography of the abdomen and pelvis demonstrated extensive hemoperitoneum and numerous cervical, mesenteric and inguinal enlarged lymph nodes. Laparoscopy was performed and abundant hemoperitoneum with blood clots along the left parietocolic gutter were observed. The spleen was completely decapsulated and surrounded by a hematoma and the subcapsular tissue was bleeding. Total splenectomy was performed without complications. Splenic histology demonstrated white pulp attenuation and expansion of the red pulp with focal hemorrhage and necrosis. IgM anti-viral capsid antigen of Epstein Barr virus was positive. The patient had a satisfactory recovery.

Ruptura diafragmática y esplénica de origen traumático en un adolescente / Diaphragmatic and splenic rupture of traumatic origin in a teenager

Introducción: La ruptura diafragmática es un reto diagnóstico y terapéutico para los médicos que se enfrentan al manejo de pacientes politraumatizados; debe sospecharse siempre en lesiones traumáticas de localización torácica o abdominal. Objetivo: Informar los elementos diagnósticos y terapéuticos seguidos ante ruptura diafragmática y esplénica de origen traumático. Presentación del caso: Se presenta el caso de un adolescente de 14 años que ingresa por presentar herida punzante por arma blanca de localización abdominal y manifestaciones clínicas que permiten hacer el diagnóstico de la afección tratada. Durante el acto quirúrgico se comprobó la ruptura del diafragma, hernia diafragmática y ruptura esplénica con salida de sangre hacia la cavidad abdominal. Se realizó reducción de la hernia, sutura del diafragma y extirpación del bazo por el estado del órgano en el momento de la cirugía. Conclusiones: La ruptura diafragmática postraumática es una entidad que cada vez se observa con mayor frecuencia en pacientes pediátricos. El examen clínico auxiliado por estudios imagenológicos resulta vital para su diagnóstico, tratamiento precoz y evitar complicaciones. Es importante mantener un alto índice de sospecha ante esta entidad poco frecuente, pero no rara en la edad pediátrica. El paciente tuvo una evolución favorable y fue egresado del servicio de cirugía luego de 10 días de hospitalización(AU)

Introduction: The diaphragmatic rupture is a diagnostic and a therapeutic challenge for physicians who have to face the management of polytraumatized patients; there must always be suspicion on traumatic injuries of thoracic or abdominal location. Objective: To inform the diagnostic and therapeutic elements followed in case of diaphragmatic and splenic rupture of traumatic origin. Presentation of the case: 14-year-old male teenager that was admitted for presenting stabbing wound by sharp weapon, with abdominal location and clinical manifestations that allow making the diagnosis of the condition being treated. During surgery, it was found the rupture of the diaphragm, a diaphragmatic hernia and splenic rupture with output of blood into the abdominal cavity. It was conducted the reduction of the hernia, the suture of the diaphragm and the removal of the spleen due to the state of the organ during the surgery. Conclusions: Post-traumatic diaphragmatic rupture is an entity that it is most often seen in pediatric patients. The clinical examination aided by imaging studies is vital for its diagnosis, early treatment and to avoid complications. It is important to maintain a high index of suspicion to face this rare entity, but not so rare in the pediatric age group. The patient had a favourable evolution and he was discharged of the surgery service after 10 days of hospitalization(AU)

Ruptura esplênica secundária à infeção por Plasmodium falciparum / Splenic rupture secondary to Plasmodium falciparum infection

A ruptura esplênica é uma complicação possível da malária. É importante pela dificuldade diagnóstica, pois um elevado índice de suspeição é necessário para um diagnóstico atempado. Pode condicionar uma hemorragia intraperitoneal e deve ser considerada no diagnóstico diferencial de quadros de dor abdominal, hipotensão e diminuição do hematócrito. Os autores descrevem o caso de um homem de 59 anos, com ruptura esplênica secundária à malária por Plasmodium falciparum, tendo realizado esplenectomia urgente. Com a apresentação do caso, os autores pretendem chamar a atenção para a necessidade de incluir esta afecção no diagnóstico diferencial dos doentes com malária e hipotensão refractária.

Splenic rupture is a possible complication of malaria. Due to its difficult diagnosis, it is important, because a high level of suspicion is needed for a timely diagnosis. It results in intraperitoneal bleeding and should be considered in the differential diagnosis of abdominal pain, hypotension and low hematocrit. The authors report the case of a 59-year old man with splenic rupture secondary to malarial infection by Plasmodium Falciparum, who was treated with urgent splenectomy. This case is presented to remind the clinicians of include this entity in the differential diagnosis of patients with malaria and refractory hypotension.

Incidental splenic injury and splenectomy: an overview based on available evidence / Lesión esplénica incidental y esplenectomía: una visión general basada en la evidencia disponible

Splenectomy indications are hematologic disease, traumatic damage and iatrogenic injury. The aim of this study was to present an evidence-based overview of some clinical aspects of interest related with iatrogenic splenic injury and subsequent splenectomy. An overview of the available evidence was conducted. Articles that evaluated clinical aspects of interest related with iatrogenic splenic injury and subsequent splenectomy, without language limits, publication date and designs. BVS, PubMed, SciELO and TRIP databases were reviewed. Evaluated variables were: Frequency and etiology of surgical spleen injuries, treatment options, frequency of splenectomy, associated postoperative morbidity (POM) and mortality, recommendation for splenectomy. Classification of the available evidence was made using the classification proposed by Oxford Centre of Evidence-based Medicine. 1144 records were obtained. 1109 were discarded for not meeting eligibility criteria, or were not relevant for the purpose of this research. Finally, the study consisted of 35 articles, 3 of evidence level type 3a, 31 of evidence level type 4 and 1 of evidence level type 5. Splenectomy is a complication of common abdominal procedures, prevalence and incidence of iatrogenic splenic injury is underestimated because of lack of information, there is evidence of risk factors of surgical spleen injuries, the etiology of surgical spleen injuries are bariatric, esophago-gastric, antireflux, colorectal, abdominal vascular and urological procedures. POM in patients undergoing splenectomy is more frequent in emergency splenectomy secondary to trauma. There was no significant risk reduction of infectious complications after implementation of routine vaccination. Available evidence is based on few and heterogeneous articles, which make a meaningful conclusions difficult. Studies with better evidence levels, methodological quality and population size are needed for conclusions and recommendations.

Las indicaciones de esplenectomía son enfermedades hematológicas, daño por trauma y por lesiones iatrogénicas. El objetivo de este estudio es presentar una visión general basada en la evidencia actualmente disponible, respecto de algunos aspectos clínicos de interés relacionados con la lesión esplénica iatrogénica y posterior esplenectomía. Revisión global de la evidencia disponible. Se incluyeron artículos que evaluaron aspectos clínicos de interés relacionados con lesión esplénica iatrogénica y posterior esplenectomía; sin límites de lenguaje, fecha de publicación y diseño. Se revisaron las bases de datos BVS, PubMed, SciELO y Trip Database. Las variables evaluadas fueron: frecuencia y etiología de las lesiones, opciones de tratamiento, frecuencia de esplenectomía, morbimortalidad postoperatoria, recomendación de esplenectomía. La clasificación de la evidencia se realizó con la propuesta del Centro de Medicina Basada en la Evidencia de Oxford. Se obtuvieron 1144 registros. 1109 fueron descartados por no cumplir criterios de elegibilidad, o ser no relevantes para el objetivo de la investigación. La población en estudio quedó compuesta por 35 artículos, 3 de nivel de evidencia 3a, 31 de nivel de evidencia 4 y 1 de nivel de evidencia 5. La esplenectomía es una complicación propia de la cirugía abdominal. La prevalencia e incidencia de lesión esplénica iatrogénica es subestimada por falta de información. Hay evidencia de factores de riesgo de lesiones del bazo. La etiología de estas es: procedimientos bariátricos, esófago-gástricos, colorrectales, vasculares abdominales y urológicos. La morbilidad es más frecuente en esplenectomía de emergencia secundaria a trauma. No se ha registrado disminución significativa del riesgo de complicaciones infecciosas con la vacunación rutinaria. La evidencia disponible se basa en pocos artículos y heterogéneos, lo que impide sacar conclusiones. Se necesitan estudios de mejor nivel de evidencia, calidad metodológica y tamaño de muestra para obtener conclusiones válidas y recomendaciones adecuadas.

Spontaneous splenic rupture due to dengue fever: report of two cases

Dengue is a febrile illness caused by Flavivírus and mainly transmitted by the mosquito Aedes aegypiti which have been a serious epidemic in Rio de Janeiro. In most of cases it was a self limited disease. We report two cases of a serious and rare complication of this viral infection.

Spontaneous rupture of amyloid spleen

Primary systemic amyloidosis [AL] is characterized by the overproduction of immunoglobulin light chain proteins by a monoclonal, terminally differentiated B-lymphocyte or plasma cell clone. The free immunoglobulin light chains are deposited in an abnormal conformation as amyloid in a variety of organs in the body [1]. Splenic involvement is seen in 4 -13% of cases, however amyloidosis causing spontaneous rupture is very rare with only 31 cases reported so far. We report a case of 60-year old, suffering from Primary AL amyloidosis and multiple myeloma involving the liver, spleen and GI tract, who suddenly collapsed and developed rapid abdominal distension. CT scan suggested rupture of the spleen. She underwent emergency Splenectomy and had an uneventful recovery. It has been suggested that the deposition of amyloid in the basement membrane of the vascular endothelium leads to increased gap between junctions and leading to vascular fragility and propensity to rupture. The amyloid can also lead to defective interaction with platelets and predispose to spontaneous haemorrhage. Thus in a case of occult haemorrhage with Amyloidosis, diagnosis of rupture of spleen should be considered and CT scan should be performed if the patient is haemodynamically stable. Splenectomy is the ideal treatment for ruptured spleen

Rotura traumática del diafragma: revisión de siete casos / Traumatic diaphragmatic rupture: a review of seven cases

Introducción: la rotura traumática del diafragma es una lesión infrecuente que aparece en politraumatismos o agresiones. Predomina en los varones entre 20 y 50 años de edad, siendo los accidentes de tráfico la principal causa en Europa. El diagnóstico preoperatorio requiere alto nivel de sospecha junto con las adecuadas exploraciones radiológicas. El retraso diagnóstico se asocia con elevada morbilidad y mortalidad, constituyendo la intervención quirúrgica inmediata un factor determinante para el éxito en el tratamiento de estos pacientes. El objetivo de este informe fue analizar la incidencia y epidemiología de la rotura traumática del diafragma en nuestro medio, y exponer nuestros resultados en el diagnóstico y tratamiento de esta lesión. Material y métodos: presentamos siete casos correspondientes al periodo 1999-2005 y analizamos el motivo de ingreso, la clínica, las formas de diagnóstico, las lesiones asociadas, el tratamiento y la evolución. Conclusiones: el diagnóstico de rotura diafragmática es difícil debido a su baja frecuencia y a su sintomatología variable, no obstante, debe ser considerado en todo paciente politraumatizado. La tomografía helicoidal es la exploración radiológica de elección y la vía de abordaje más adecuada es la laparotomía media.

BACKGROUND: Traumatic diaphragmatic rupture is an infrequent lesion usually found in polytrauma cases or after violent attacks. Patients are usually males between 20 and 50 years old, and car accidents are the main causes in Europe. Preoperative diagnosis must be based on a high level of suspicion and appropriate radiological explorations. Diagnostic delay is associated with high morbidity and mortality and early surgical treatment is required for successful management. We undertook this study to analyze the epidemiology of diaphragmatic rupture and to report our results in the diagnosis and treatment of this injury. METHODS: We present seven cases from 1999 through 2005. We analyzed the reasons for admission, signs and symptoms, diagnostic approach, associated lesions, treatment and course. CONCLUSION: Diagnosis of diaphragmatic rupture is difficult due to changeable symptomatology; nevertheless, it must be considered in all polytraumatized patients. Computerized tomography is the radiological exploration of choice and the most suitable surgical approach is laparotomy.

Ruptura esplénica espontanea secundaria a amiloidosis / Spontaneous splenic rupture due to amyloidosis

La ruptura esplénica se produce frecuentemente por mecanismos traumáticos. Se la denomina espontánea o patológica cuando no existe tal antecedente o hay alguna patología esplênica predisponente. La ruptura esplénica espontánea por infiltración amiloide es una causa muy infrecuente de abdômen agudo quirúrgico. Se presenta el caso de una mujer internada por abdomen agudo secundario a ruptura esplénica espontánea, cuyo diagnóstico final fue amiloidosis primaria.

La esplenectomía segmentaria sobrepasa los pronósticos / The segmentary splenectomy exceeds the prognoses

Sesenta pacientes a los que se les realizó esplenectomía total por ruptura traumática del bazo, sin lesiones asociadas, ni enfermedades concurrentes, fueron comparados con 60 a los que se les efectuó una esplenectomía segmentaria reglada, pero no gozaron de los criterios de selección antes mencionados; aunque ambas muestras tienen características similares en cuanto a edad, sexo, seguimiento mayor de 5 años y estar operado en el Servicio de Urgencias Provincial de Pinar del Río a partir de 1985. El objetivo fue conocer las ventajas y desventajas de aplicar la cirugía conservadora y los resultados demostraron que la segmentectomía es seguida de menos complicaciones, menor mortalidad intrahospitalaria y durante el seguimiento estadísticamente significativos con p<0,05; además se observó que estos resultados disminuyen la estadía y reducen el costo hospitalario, por lo que se deduce que la aplicación de la esplenectomía segmentaria reglada es mejor para los pacientes a corto y a largo plazo y beneficia al Sistema de Salud

60 patients who underwent total splenectomy due to traumatic spleen rupture without associated lesions or concurrent diseases, were compared with 60 cases that underwent ruled segmentary splenectomy without the above-mentioned selection criteria, eventhough both samples had similar characteristics as regards age, sex, follow-up for more than 5 years and they had been operated on at the Provincial Emergency Service of Pinar del Río, from 1985 on. The objective was to know the advantages and disadvantages of performing conservative surgery. The results showed that segmentectomy present less complications and intrahospital mortality and statistically significant results with p < 0.05 during the follow-up. It was also observed that these results reduce the hospital stay and cost and that's why is it is considered that the application of ruled segmentary splenectomy is better for patients on the short and long term and that it benefits the health system(AU)

Management of splenic trauma in children

To study the possibility of conservative management of splenic injuries in children with isolated and non-severe lesions. Patients and The records of 39 pediatric patients [<18 y] with splenic injures from blunt trauma were reviewed in this retrospective study which covered 6 years. We identified 3 groups: Group I: [n = 17] operative group in unstable or polytraumatized children. Group II: [n = 7] delayed operative group in children with associated injuries. Group III: [n = 15] absence of associated injuries. Conservative management. There was no statistical difference between group II and III concerning length of hospitalization and volumes of transfused blood. In these groups, volume transfused seemed to correlate with associated lesions These data confirm that the majority of children with blunt splenic injury can be successfully treated without surgery. In cases of instability, multiple associated lesions, or suspected intestinal disruption confirmed by peritoneal lavage, early operation must be recommended

Does associated injuries affect the modality of [NOM] for blunt splenic injuries in children

Over 4-y 1177 c.s period 114 children [1-14] years of age with documented splenic injury after Blunt Abdominal Trauma [BAT] were retrospectively reviewed. The study group was divided into 2 main categories; Category-l, included 62 patients [54.4%] with isolated splenic injury [ISI]. Category-2, included 52 patients [45.6%] with associated injuries [AI]. This category was subdivided into 3 groups: Group-1 included 16 patients [14%] with associated intra-abdominal injury [AIAI].Group-2 included 26 patients [22.8%] with associated extra-abdominal injury [AEAI]. Group-3 included 10 patients [8.8%] with associated intra-extra-abdominal injuries [AIEAI]. All patients were managed and investigated, the effect of associated injuries on the modality of non- operative management [NOM] was discussed. The results of the study showed that in AI cases 34.6% were transfused with blood a mean of 2.6 U, while only 12.9% of cases of ISI were transfused with a mean of 2 U. NOM was adopted in 90.3% of ISI cases with success rate of 96.4%, while it was adopted in 80.7% of AI cases with success rate of 90.5%, the least success rate was recorded in AIEAI cases 83.3% of 60% adopted cases, in 40% of cases of this group immediate operative management was indicated

Trauma de Bazo / Spleen Trauma

El trauma de bazo tiene una prevalencia del 6 por ciento de los órganos lesionados durante el trauma abdominal cerrado debido a su localización en la porción superior del abdomen; es el órgano intraabdominal que más se lesiona en este tipo de trauma y en las heridas penetrantes del cuadrante superior izquierdo. Si existe esplenomegalia la ruptura puede ocurrir por traumas mínimos. Iatrogénicamente se puede lesionar en procedimientos como arteriografías, colangiografías, esfinterotomías retrógradas endoscópicas, masajes cardíacos, toracentesis bajas, paracentesis en pacientes con esplenomegalias o con hematoms subcapulares y en cirugías como gastrectomías, colectomías y cirugías pancreáticas. Generalmente, ocurre hemorragia intraabdominal masiva por lo que los síntomas son los asociados a hemorragia intraperitoneal (shock, signos de irritación peritoneal, signo de Kehr's, signo de Ballances). En el hemograma pueden aparecer leucocitosis de 12x10(9)/L y el hematócrito, si la hemorragia es muy profusa, se disminuye después de seis horas. El manejo médico comprende un monitoreo adecuado de las funciones vitales y del volumen urinario horario, control de la hemoglobina y el hematocrito y el reemplazo de líquidos, electrolitos y de sangre; el manejo conservador puede ir desde el sólo manejo médico, embolectomía o manejo quirúrgico como esplenectomía parcial, esplenorragia o colocación de mallas por laparotomía formal o por laparoscopia, lo que cada vez es más aceptado en la mayoría de los centros de trauma

Traumatismo esplênico / Splenic trauma

Os autores apresentam estudo retrospectivo de 130 pacientes vítimas de traumatismo esplênico tratados no Serviço de Cirurgia de Urgência do Hospital Municipal Djalma Marques, em São Luís - MA, no período de janeiro de 1990 a dezembro de 1995. Haviam 110 pacientes do sexo masculino (84,6 por cento) e 20 do sexo feminino (15,4 por cento), com média de idade de 22,6 anos. O principal mecanismo de lesão foi o trauma contuso e o tratamento cirúrgico consistiu em esplenoctomia total na maioria dos pacientes. A infecção da ferida operatória foi a complicação mais freqüente e ocorreram nove óbitos (6,9 por cento). Os autores discutem e destacam o valor do autotransplante esplênico nos casos de esplenectomia total.

Cirugía del traumatismo esplénico / Surgery of splenic injury

Con el objetivo de analizar nuestra experiencia frente a los traumatismos del bazo y sus resultados, revisamos el tratamiento quirúrgico de los traumatismos esplénicos en el período 1982-1993. Fueron operados 26 pacientes, todos secundarios a una contusión abdominal. Destaca que 22 de 26 son politraumatizados con un ISS medio de 25. Existieron 3,17 lesiones intraabdominales por paciente siendo el hígado, riñ+on y diafragma los órganos más frecuentemente asociados. Se practicó una esplenectomía en 14 pacientes, con una mortalidad del 7,1 porciento. En los 12 restantes se efectuó cirugía conservadora del bazo, mediante técnicas de sutura, uso de agentes tópicos y malla reabsorbible. En este grupo no hubo mortalidad ni necesidad de reexploraciones. Entre ambos grupos no hubo diferencias entre el ISS (25 versus 27) ni en el tiempo operatorio (120 minutos versus 125 minutos). Destaca que en el grupo de esplenorrafia la mayoría de las lesiones fueron de grado I al III. Creemos demostrar que se puede aplicar en forma segura un tratamiento quirúrgico selectivo en adultos con traumatismo del bazo, con un 46,4 porciento de éxito en la preservación esplénica

Rotura tardía del bazo: un riesgo del tratamiento conservador / Late splenic rupture: a risk of conservative treatment

We report a 33 years old male admitted after a traffic accident with painful abdomen and an open ankle fracture. An abdominal CAT scan showed a splenic laceration and free ascitis. A conservative treatment was decided considering that the patient was hemodynamically stabilized. Seven days later, the patient appeared hypotense and with severe pain and was operated. During surgical intervention, a masive hemoperitoneum due to splenic bleeding from the spleen was found and a splenectomy was performed. Postoperative outcome was uneventful. The therapeutic approach to splenic traumatism ranges from splenectomy to medical treatment. The report case is an example of a complication of this later approach

Comparative study of hematological and immunological responses to splentectomy versus splenic autotransplantation in patients with traumatic rupture of the spleen

The present study was carried out on 20 male patients admitted to the Main Alexandria University Hospital with traumatic rupture of the spleen. Group 1 patients [n=10] were subjected to total splenectomy with intraperitoneal splenic tissue autotransplantation via an omental pouch, while group 2 patients [n=10] were subjected to total splenectomy alone and served as controls. Both groups were compared, utilizing hematological and immunological parameters measured preoperatively and 4 weeks and 8 weeks postoperatively, in order to assess function of the splenic implants. Results revealed partial restoration of splenic function as reflected by a statististically significant reduction [P<0.05] of the mean percentage of vaculated RBCs at 8 weeks postoperatively as compared to controls and significant increase of serum IgM levels at 8 weeks postoperatively as compared to their level at 4 weeks. Based on these data, it may be concluded that whenever total splenectomy is unavoidable following trauma, intraperitoneal autotransplantation of splenic tissue restores, at least partially, splenic function, particularly its role as a blood filter

Actualización en el tratamiento conservador de las lesiones esplénicas traumáticas / Up-date in conservative treatment of the traumatic splenic lesions

Existen diversas posibilidades terapéuticas frente a la lesión esplénica traumática. El objetivo de conservar la función del bazo es primordial para evitar complicaciones sépticas en el paciente esplénico. Para ello se requiere efectuar un diagnóstico preciso del tipo de lesión e instaurar el tratamiento conservador en la medida de lo posible. Es motivo de la presente comunicación hacer una revisión de los distintos recursos terapéuticos ante las lesiones del bazo