Endgames Picture Quiz

Abdominal trauma

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d882 (Published 13 April 2011) Cite this as: BMJ 2011;342:d882
  1. Rhodri H Davies, senior house officer in medicine1,
  2. Brian I Rees, consultant in general surgery1
  1. 1University Hospital of Wales, Cardiff, UK
  1. Correspondence to: RH Davies daviesrh2{at}cardiff.ac.uk

A 61 year old woman with advanced oesophageal cancer was brought by ambulance to the accident and emergency department after falling down the stairs at her home. On arrival, her memory of events was vague, but she recalled tumbling down six or seven steps and hitting her left flank and head as she fell. She did not remember “blacking out” or noticing anything unusual before the fall. She complained of severe left sided abdominal pain, exacerbated by breathing, and of profound weakness in her left arm and leg, which had been present for weeks.

On examination, her blood pressure was 120/78 mm Hg, pulse was 98 beats/min, respiratory rate was 28 breaths/min, and oxygen saturation was 100% on 100% oxygen. Abdominal examination revealed marked tenderness in the left upper quadrant, with some guarding and percussion tenderness; no organomegaly or mass was detected. Her Glasgow coma scale score was 15/15, and the only neurological deficit was a dense left hemiparesis. Examination of other systems was unremarkable. The only abnormality in the initial blood tests was a haemoglobin concentration of 108 g/L.

Contrast enhanced computed tomography images were obtained of the head and abdomen. The head scan ruled out acute haemorrhage, but revealed a probable metastatic tumour in the right fronto-parietal region. The abdominal images are shown in figs 1 and 2.

Fig 1 Axial contrast enhanced computed tomography image of the patient’s abdomen

Fig 2 Coronal contrast enhanced computed tomography image of the patient’s abdomen

Questions

  • 1 What abnormalities can be seen on the computed tomography scans?

  • 2 How would you grade this condition?

  • 3 Following initial resuscitation, what are the management options?

  • 4 What long term management should to be considered?

Answers

1 What abnormalities can be seen on the computed tomography scans?

Short answer

The scans show a large laceration of the spleen, with capsular involvement, and a perisplenic haematoma (figs …

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