ACUTE ABDOMENSurgical Emergencies 267Ruptured spleen
DIAGNOSIS
1 Left lower rib injuries following blunt trauma are associated with splenic
damage in up to 20% of cases. Occasionally, trivial injury to an already
enlarged spleen from glandular fever, malaria or leukaemia can cause
rupture.
2 The timing of the splenic rupture may be:
(i) Acute: causing tachycardia, hypotension and abdominal
tenderness with pain referred to the left shoulder.
(ii) Delayed: occurring up to 2 weeks or more after an episode of
trauma. Initial localized discomfort and referred shoulder-tip
pain give way to signs of intra-abdominal haemorrhage.
3 Gain large-bore i.v. access and send blood for a FBC and cross-match 6 units
of blood for an acutely ruptured spleen.
4 Request a CXR to look for fractured left lower ribs and a basal pleural
effusion, especially in delayed splenic rupture.
(i) AXR is unhelpful, as features are non-specific such as a displaced
stomach bubble to the right and an enlarged soft-tissue shadow
in the splenic area.
5 Arrange an urgent upper abdominal ultrasound if the patient is unstable, or
a CT scan wit h i.v. contrast if t he patient is stable.
MANAGEMENT1 Commence an infusion of normal saline and refer the patient immediately to
the surgical team.
Acute pancreatitis
DIAGNOSIS
1 Predisposing factors include alcohol abuse, gallstones, viruses such as
mumps, Epstein–Barr virus and cytomegalovirus, trauma, ischaemia or
vasculitis, and following endoscopic retrograde cholangiopancreatography
(ERCP).
2 Acute pancreatitis presents with sudden, severe abdominal pain radiating to
the back, that is eased by sitting forward, associated with repeated vomiting
or retching.
3 Vital signs may reveal a low-grade fever and tachycardia with hypotension.
4 Look for epigastric tenderness, guarding and decreased or absent bowel
sounds on abdominal examination.
5 Insert a large-bore i.v. cannula and send blood for FBC, U&Es, LFTs, blood
sugar, ca lcium, lipase/amylase and G&S. Check an arteria l blood gas.