Theadora Forster-Anderson and Rita Poon
Fiona Stanley Hospital, Australia
Royal Australasian College of Surgeons, Australia
Posters & Accepted Abstracts: Surgery Curr Res
Introduction: Atraumatic splenic and peri-splenic haemorrhage accounts for 1/5 splenic bleed. Those without intra-capsular haemorrhage are less common and not widely documented. When bleeds occur without trauma, it tends to be in the presence of portal hypertension from liver cirrhosis, haematological malignancy, infection, primary hepatoma, pancreatitis, pregnancy or amyloidosis. Case: A 72-year-old presented with acute epigastric pain, tachycardia, hypotension, fever and a tender abdomen. History included prostate cancer, deep vein thrombosis and pulmonary embolism (DVT/PE) (on warfarin), essential thrombocytosis, portal vein thrombosis, and heparin induced thrombosis--thrombocytopenia syndrome (HITTS). Haemoglobin was stable and INR 2.3. CT revealed bleeding from a small region of peri-splenic veins. The patient was stabilized and INR reversed using prothrombinex. Clotting disorders were screened and indicated JAK-2 genetic disorder. Haematology recommended Fondaparinux, fresh frozen plasma, platelets, and tranexamic acid. On day 3 in ICU, blood pressure dropped, CT was repeated (Images 1, 2), and the patient was taken to theatre where he was found to have frank hemoperitoneum. Medtronic stapler was fired along bleeding vessels with successful hemostasis. Due to bleeding extent and risk of further injury, the decision was made to complete the operation. He then developed lower limb DVT where his access line was placed. ICU, hematology, general surgical and vascular teams all concluded it would be unsafe to anti-coagulate due to bleeding. DVT progressed to venous infarction and limb ischaemia. The patient was palliated and passed away from multiple organ failure. Conclusion: In this patient, raised venous pressures lead to variceal dilation and splenomegaly. Dilated, friable veins are prone to spontaneous rupture. Bleeding was exacerbated by warfarin and having a pre-existing clotting disorder. Ultimately the balance between managing his clotting issues and preventing further bleeding was too delicate to be maintained. Despite prompt diagnosis, this case was not traumatic, making management decisions difficult. This case aims to add to the database of this rare but fatal condition.
Theadora Forster-Anderson is a Surgical Registrar practicing in a service role at Fiona Stanley Hospital in Perth. She was recently posted at Gosford Hospital in New South Wales (NSW), where this case was encountered. She is interested in the field of General Surgery including the evaluation and management of trauma cases. She is a Consultant General Surgeon practicing on the Central Coast in NSW.