Case contribution: Dr Radhiana Hassan
Clinical:
- A 13 years old male
- Fall from motorbike
- No loss of consciousness
- Complaint of abdominal pain
CT scan findings:
- There are multiple small intraparenchymal hematoma seen (red arrows)
- A laceration is also seen at lower pole about 2 cm (yellow arrow)
- There is associated perisplenic blood collection (white arrow)
- Other organs are normal.
Diagnosis: Grade II spleen injury
Discussion:
- Grade II spleen injury is defined as subcapsular hematoma is 10-50% of surface area
- or with intraparenchymal hematoma of less than 5 cm in diameter
- or intraparenchymal laceration 1-3 cm depth that does not involve trabecular vessel
Progress of patient:
- Initially treated conservatively
- In ward Hb drop from 12 to 8.6
- Had blood transfusion with one DIVC regime
- Subsequently operation done due to failed conservative management
- Intraoperative findings: Laceration at tip of spleen about 4 cm. Hilum intact. Contusion at pancreatic tail. Hemoperitoneum about 1100 cc.
- Splenectomy done
- He was discharged 4 days after the operation (Day 6 of admission)
- Subsequent follow up: patient was well
