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Spontaneous splenic rupture due to uremic coagulopathy and mortal sepsis after splenectomy.

Gazel E, Açıkgöz G, Kasap Y, Yiğman M, Güneş ZE - Int J Crit Illn Inj Sci (2015 Apr-Jun)

Bottom Line: Following clearance of the retroperitoneal hematoma, splenectomy was implemented.Experiencing progressive deterioration in his clinical status despite antibiotherapy, the patient unfortunately died of sepsis with multiorgan failure on the 25(th) postoperative day.In conclusion, NSSR is such an entity that may be missed out, can pursue variable clinical courses, and requires emergency therapy upon definitive diagnosis.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Turkey Yüksek İhtisas Training and Research Hospital, Ankara, Turkey.

ABSTRACT
Nontraumatic spontaneous splenic rupture (NSSR) has been encountered much more rarely compared with the traumatic splenic rupture. Although NSSR generally emerges in dialysis patients on account of such causes as the use of heparin during hemodialysis, uremic coagulopathy, infections, and secondary amyloidosis. Herein, we aimed to present a case of spontaneous splenic rupture which had developed soon after the inclusion of the case suffering from end-stage renal disease in routine hemodialysis program in the absence of any trauma or other prespecified risk factors for splenic rupture. A 55-year-old male patient was admitted to our hospital to have the ureteral double J stent removed. The operation was completed without any complication. Complaining an abdominal pain more prominent in the left upper abdominal quadrant in the first postoperative day, the patient underwent a through physical examination which disclosed abdominal distension, widespread tenderness, and rebound and defense positivity. The abdominal tomography depicted 122 × 114 × 95 mm lesion compatible with a hematoma. On the basis of these findings, an emergency exploratory operation was decided to be performed. Following clearance of the retroperitoneal hematoma, splenectomy was implemented. Experiencing progressive deterioration in his clinical status despite antibiotherapy, the patient unfortunately died of sepsis with multiorgan failure on the 25(th) postoperative day. In conclusion, NSSR is such an entity that may be missed out, can pursue variable clinical courses, and requires emergency therapy upon definitive diagnosis. The possibility of spontaneous bleedings should be kept in mind in any case with the history of hyperuricemia even in the absence of overt trauma, no matter if they are included in routine hemodialysis or not.

No MeSH data available.


Related in: MedlinePlus

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Figure 1: CT image

Mentions: A 55-year-old male patient was admitted to our hospital to have the ureteral double J stent removed, which had been implanted during endoscopic treatment of left ureteric calculus 1 month previously. His medical history revealed no specific disease condition or surgical intervention other than being under a follow-up program for compensated chronic renal failure for 1 year, a daily dieresis of 2500 cc volume and the ureteroscopic intervention 1 month previously. In the laboratory analysis, blood glucose, urea, creatinin, uric acid, sodium and potassium levels were measured to be 110 mg/dL, 259 mg/dL, 8.8 mg/dL, 7.4 mg/dL, 138 mmol/L, 4.93 mmol/L, respectively. Moreover, the liver function tests were within normal range; hemoglobin level, hematocrit, white blood cell (WBC) count, platelet count were detected to be 7.7 gr/dL, 24 (%), 6000/uL, 250.000/uL, respectively, together with normal prothrombin (PT) and activated partial thromboplastin times (aPTT). Urinary system ultrasonography reported bilateral reduced kidney sizes and increased parenchymal echogenicity compatible with ESRD. With respective creatinin clearance and protein level detected to be 7.9 mL/min and 2364 mg/day in 24-hour urine test, the patient was then included in routine hemodialysis program after having been consulted to the department of nephrology. The ureteric catheter was removed through cystoscopy under sedation in the operating theater 1 day after the second hemodialysis session. The operation was completed in a total of 10 min without any complication. Complaining an abdominal pain more prominent in the left upper abdominal quadrant in the 1st postoperative day, the patient underwent a through physical examination which disclosed abdominal distension, widespread tenderness, and rebound and defense positivity. As for his vital signs, the body temperature was 36.5°C; pulse rate was 105/min; respiratory rate was 20/min; and, blood pressure was 85/50 mm Hg. Laboratory analysis revealed the following findings: Urea 119 mg/dL; creatinin 4.2 mg/dL; sodium140 mmol/L; potassium 4.16 mmol/L; hemoglobin 6.7 gr/dL; hematokrit 19.9 (%); WBC count 8000/uL; platelet count 57.000/uL; PT 21.7 s; aPTT 110 s; and, INR 1.91. The abdominal tomography depicted a high-density (75 HU) lesion of 122 × 114 × 95 mm dimension compatible with a hematoma which was localized in retroperitoneal region and extending from left upper renal pole, where it possessed an indistinguishable border into the subdiaphragmatic area [Figure 1]. On the basis of these findings, an emergency exploratory operation was decided to be performed on the patient. During the exploration, free fluid with hemorrhagic character was observed in the abdomen, together with a number of capsular laceration sites and accompanying hematomas. Following clearance of the retroperitoneal hematoma, splenectomy was implemented. Fresh whole blood, fresh frozen plasma, and thrombocyte suspension were transfused intraoperatively, four units for each. Suffering from persistent thrombocytopenia and high INR level despite stable vital signs and hemoglobin and hematocrit levels, the patient was then consulted to the department of hematology. Following a definitive diagnosis of uremic coagulopathy by the department of hematology, the patient was put under close monitorization together with platelet and fresh frozen plasma replacements. On the postoperative 3rd day, all the blood parameters became stabilized, rendering further transfusions unnecessary. Furthermore, complying with the recommendations by the department of infectious diseases, a set of pneumococcal, Haemophilus influenza type B (Hib), and meningococcal vaccines were administered postoperatively to the patient. On the 10th postoperative day, the patient was consulted to the chest physician due to emergence of respiratory distress and high fever. Suspected to have incurred a pulmonary thromboembolism, the patient underwent a pulmonary computed tomography angiography, which depicted no thromboembolism. On the strength of both sputum and blood culture positivity for the growth of Acinetobacter, intravenous colimycin therapy was commenced on the recommendations of the infectious disease physician. Thereafter, he was transferred to the intensive care unit for more stringent monitorization due to persistent high fever, deteriorating respiratory distress, progressive hypotension, and emerging need for further oxygen therapy. Experiencing progressive deterioration in his clinical status despite antibiotherapy, the patient unfortunately died of sepsis with multiorgan failure on the 25th postoperative day.


Spontaneous splenic rupture due to uremic coagulopathy and mortal sepsis after splenectomy.

Gazel E, Açıkgöz G, Kasap Y, Yiğman M, Güneş ZE - Int J Crit Illn Inj Sci (2015 Apr-Jun)

CT image
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4477390&req=5

Figure 1: CT image
Mentions: A 55-year-old male patient was admitted to our hospital to have the ureteral double J stent removed, which had been implanted during endoscopic treatment of left ureteric calculus 1 month previously. His medical history revealed no specific disease condition or surgical intervention other than being under a follow-up program for compensated chronic renal failure for 1 year, a daily dieresis of 2500 cc volume and the ureteroscopic intervention 1 month previously. In the laboratory analysis, blood glucose, urea, creatinin, uric acid, sodium and potassium levels were measured to be 110 mg/dL, 259 mg/dL, 8.8 mg/dL, 7.4 mg/dL, 138 mmol/L, 4.93 mmol/L, respectively. Moreover, the liver function tests were within normal range; hemoglobin level, hematocrit, white blood cell (WBC) count, platelet count were detected to be 7.7 gr/dL, 24 (%), 6000/uL, 250.000/uL, respectively, together with normal prothrombin (PT) and activated partial thromboplastin times (aPTT). Urinary system ultrasonography reported bilateral reduced kidney sizes and increased parenchymal echogenicity compatible with ESRD. With respective creatinin clearance and protein level detected to be 7.9 mL/min and 2364 mg/day in 24-hour urine test, the patient was then included in routine hemodialysis program after having been consulted to the department of nephrology. The ureteric catheter was removed through cystoscopy under sedation in the operating theater 1 day after the second hemodialysis session. The operation was completed in a total of 10 min without any complication. Complaining an abdominal pain more prominent in the left upper abdominal quadrant in the 1st postoperative day, the patient underwent a through physical examination which disclosed abdominal distension, widespread tenderness, and rebound and defense positivity. As for his vital signs, the body temperature was 36.5°C; pulse rate was 105/min; respiratory rate was 20/min; and, blood pressure was 85/50 mm Hg. Laboratory analysis revealed the following findings: Urea 119 mg/dL; creatinin 4.2 mg/dL; sodium140 mmol/L; potassium 4.16 mmol/L; hemoglobin 6.7 gr/dL; hematokrit 19.9 (%); WBC count 8000/uL; platelet count 57.000/uL; PT 21.7 s; aPTT 110 s; and, INR 1.91. The abdominal tomography depicted a high-density (75 HU) lesion of 122 × 114 × 95 mm dimension compatible with a hematoma which was localized in retroperitoneal region and extending from left upper renal pole, where it possessed an indistinguishable border into the subdiaphragmatic area [Figure 1]. On the basis of these findings, an emergency exploratory operation was decided to be performed on the patient. During the exploration, free fluid with hemorrhagic character was observed in the abdomen, together with a number of capsular laceration sites and accompanying hematomas. Following clearance of the retroperitoneal hematoma, splenectomy was implemented. Fresh whole blood, fresh frozen plasma, and thrombocyte suspension were transfused intraoperatively, four units for each. Suffering from persistent thrombocytopenia and high INR level despite stable vital signs and hemoglobin and hematocrit levels, the patient was then consulted to the department of hematology. Following a definitive diagnosis of uremic coagulopathy by the department of hematology, the patient was put under close monitorization together with platelet and fresh frozen plasma replacements. On the postoperative 3rd day, all the blood parameters became stabilized, rendering further transfusions unnecessary. Furthermore, complying with the recommendations by the department of infectious diseases, a set of pneumococcal, Haemophilus influenza type B (Hib), and meningococcal vaccines were administered postoperatively to the patient. On the 10th postoperative day, the patient was consulted to the chest physician due to emergence of respiratory distress and high fever. Suspected to have incurred a pulmonary thromboembolism, the patient underwent a pulmonary computed tomography angiography, which depicted no thromboembolism. On the strength of both sputum and blood culture positivity for the growth of Acinetobacter, intravenous colimycin therapy was commenced on the recommendations of the infectious disease physician. Thereafter, he was transferred to the intensive care unit for more stringent monitorization due to persistent high fever, deteriorating respiratory distress, progressive hypotension, and emerging need for further oxygen therapy. Experiencing progressive deterioration in his clinical status despite antibiotherapy, the patient unfortunately died of sepsis with multiorgan failure on the 25th postoperative day.

Bottom Line: Following clearance of the retroperitoneal hematoma, splenectomy was implemented.Experiencing progressive deterioration in his clinical status despite antibiotherapy, the patient unfortunately died of sepsis with multiorgan failure on the 25(th) postoperative day.In conclusion, NSSR is such an entity that may be missed out, can pursue variable clinical courses, and requires emergency therapy upon definitive diagnosis.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Turkey Yüksek İhtisas Training and Research Hospital, Ankara, Turkey.

ABSTRACT
Nontraumatic spontaneous splenic rupture (NSSR) has been encountered much more rarely compared with the traumatic splenic rupture. Although NSSR generally emerges in dialysis patients on account of such causes as the use of heparin during hemodialysis, uremic coagulopathy, infections, and secondary amyloidosis. Herein, we aimed to present a case of spontaneous splenic rupture which had developed soon after the inclusion of the case suffering from end-stage renal disease in routine hemodialysis program in the absence of any trauma or other prespecified risk factors for splenic rupture. A 55-year-old male patient was admitted to our hospital to have the ureteral double J stent removed. The operation was completed without any complication. Complaining an abdominal pain more prominent in the left upper abdominal quadrant in the first postoperative day, the patient underwent a through physical examination which disclosed abdominal distension, widespread tenderness, and rebound and defense positivity. The abdominal tomography depicted 122 × 114 × 95 mm lesion compatible with a hematoma. On the basis of these findings, an emergency exploratory operation was decided to be performed. Following clearance of the retroperitoneal hematoma, splenectomy was implemented. Experiencing progressive deterioration in his clinical status despite antibiotherapy, the patient unfortunately died of sepsis with multiorgan failure on the 25(th) postoperative day. In conclusion, NSSR is such an entity that may be missed out, can pursue variable clinical courses, and requires emergency therapy upon definitive diagnosis. The possibility of spontaneous bleedings should be kept in mind in any case with the history of hyperuricemia even in the absence of overt trauma, no matter if they are included in routine hemodialysis or not.

No MeSH data available.


Related in: MedlinePlus