Case 6 - Drop in ocean, or ocean in a drop?
Author: Nish Cherian Reviewer: Nick Mani
A 72-year old female is brought into the ED by ambulance with abdominal pain. She reports a sudden onset of epigastric pain followed by syncope at home. Pre-hospital BP was 90/50 but has improved to 115/70 after 250ml bolus of IV crystalloid given by paramedics. She appears uncomfortable. Examination reveals tenderness across upper abdomen. She then has a further syncope in ED and BP drops to 60/40 transiently.
POCUS reveals the following:
Image 1. Transverse view of abdominal aorta
Clip 1. RUQ
Clip 2. LUQ
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A diameter of 3cm or greater is considered aneurysmal for the abdominal aorta
1.5cm and above is considered aneurysmal of the iliac arteries
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Free fluid is seen in the hepatorenal space and around the caudal tip of the liver.
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There is an echogenic area which appears heterogenous surrounding the spleen. This represents organised blood (i.e. a perisplenic haematoma) due to a spontaneous rupture of the spleen.
Case resolution
The patient was resuscitated with blood products and had a CT which confirmed a spontaneous splenic rupture without any active blush. She was admitted to ICU and initially managed conservatively, but later had a further bleed with haemodynamic compromise and underwent a splenectomy. Her blood results showed a WCC of >40 and it transpired she had been investigated for a non-specific myeloproliferative disorder few months prior, which is likely the underlying cause of this rare complication.
Appendix
LUQ view showing perisplenic haematoma from spontaneous splenic rupture
