Splenic rupture

Intra-parenchymal blush observed on helical CT scan

Mechanism

1) Blunt trauma (common)

2) Penetrating

3) Combination of blunt and penetrating (often seen in explosive effect)

Pathophysiology

-More common in pre existing spleen problem (Infectious mononucleosis etc)

-acute or chronic enlargement of the spleen often accompanied with thinning of splenic capsule, hence making it more fragile.

Clinical presentation (staging from I-V on CT Scan)

Minor focal injury

-right upper quadrant abdominal tenderness.

-Left shoulder tenderness due to sub diaphragmatic nerve root irritation with referred pain (Kehr Signs)

With Intra abdominal injury

- Signs of shock (>5-10% blood loss)

- abdominal distension, peritoneal signs, and overt shock (progress with the blood loss)

** Hypotension in suspected splenic rupture patient esp. who is previously healthy young man require urgent attention.

Useful procedure

-Focused abdominal sonographic technique (FAST)

- CT Scan

-MRI

Grade 4-5 splenic laceration on helical CT scan

Management

1) Conservative management in stable patient recognized by this signs

- Stable hemodynamic signs

- Stable hemoglobin levels over 12-48 hours

- Minimal transfusion requirements (2 U or less)

- CT scan injury scale grade of 1 or 2 without a blush

- Patients younger than 55 years

2) Splenic angioembolization

- Splenic artery and branches embolization with gel foam or metal coil via femoral artery

- Not perform in most hospital as it require great synchronization between trauma specialist and radiologist.

3) Surgical therapy

- In ongoing bleed patient or hemodynamic instability

- Emergency celiotomy for hemoperitoneum with suspected splenic injury (midline abdominal incision approach rather than intercostals to explore possible intra abdominal bleeding.

Complication

1) Of non operative care

- Delayed bleeding

- Splenic cyst formation

- Splenic necrosis

2) Of splenectomy

- Bleeding

- Infection by encapsulated organism, mostly pneumococcus

3) Of Angioembolism

- Noninfectious-related febrile events

- sympathetic pleural effusions

- Left upper quadrant abscesses

- Femoral arteriovenous fistulas and iliofemoral pseudoaneurysms

- Gel foam used in angioembolism may mistakenly identify as abcess

4) Other complication

- Posttraumatic splenic pseudocysts

- Thrombocytosis links with vascular problem

- Adjacent organ necrosis or abcess

Reference:

Author: H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc

Coauthor(s): Janet S Bjerke, BSN, RN, MBA, CCRC, Research Coordinator, Trauma Services, Methodist Hospital, Indianapolis

Esophageal disorder

Observe the microscopic picture

A) Describe the microscopic findings based on A and B

B) What is metaplasia

C) Name the condition in above microscopic picture

D) Name one disease associated with above changes

E) Name one complication of above changes

Answer

A) A- Squamous cell

B- Columnar cell

B) reversible change in which adult cell type is replaced by another adult cell type

C) Metaplasia of squamous epithelium into columnar epithelium.

D) Reflux esophagitis.

E) Adenocarcinoma.

biopsy of a chronic alcoholic liver

Identify the slides

A)Identify the slides
B)State the characteristic of the slides
C)Describe pathophysiology of underlying mechanism
D)In what condition we can find this condition?
E)How the diagnosis is confirmed?



Answer

A)Liver

B)– Hepatocytes can be identified
- Fat globules

C) I will upload later as i lost my diagram...

D) Alcoholic Liver Disease.

E) 1) Liver biopsy
2) Ultrasound or CT –demonstrate fatty infiltration
3) serum aminotransferase enzyme – elevated