This past week between Christmas and New Years, I worked a lot of shifts – they were memorable for the fact that they were all insanely busy. Also, many patients were insanely sick (see my last few posts for example) but this one was really out of left field. A man in his early 50′s came in in the morning complaining of abdominal pain – that started in his left lower quadrant in the middle of the night when he rolled over in bed. He was fairly healthy and active although he had two cardiac stents. No abdominal surgery in the past. He came in and was to me halfway overanxious and dramatic and halfway sick. It was sort of hard to tell at first. He had a pretty tender abdomen diffusely but when he sat upright, the pain (and tenderness) was much reduced. He dropped his BP when we started an IV and began hyperventilating. However, after 2mg of morphine, I was able to get a better exam (as he had calmed down a bit) and was still pretty tender. His labs were normal and he had no fever. A CT was ordered and although he remained fairly comfortable appearing while he was drinking his contrast, his heart rate continued to rise. As he went for CT, I was figuring he might have perforated diverticulitis at the worse or mesenteric ischaemia at the worst. When I looked at his CT (I like to look at all my CT’s where I have a suspicion of something bad instead of waiting 30 minutes for the radiologist to read them), I was shocked. It looked like he had been in a major blunt trauma. His belly was full of blood! Not air, but blood! I called a radiologist and discussed it with him – what had happened was that somehow his spleen had spontaneously burst! Most likely, he had a cyst in it that ruptured and just bled and bled and bled – mimicking a trauma CT where a person suffered a ruptured spleen from something like a baseball bat to the flank. Luckily his repeat CBC did not show too much of a drop in Hgb. He went to the OR for a probable splenectomy – although the surgeon told me he would try to repair it.
The scary thing is that he was due to go skiing the next day to a relatively remote area! That would have been the end of him…….
Not quite his lucky day, but his this could have been a whole lot worse day.
Funny…in veterinary medicine, hemoabdomen is one of the more common medical emergencies. It’s usually an older Golden Retriever or German Shepherd with a splenic hemangiosarcoma.