Blunt Spleen and Liver Trauma due to Motor Collisions: A Case Report
Abstract
Background: Motor collisions are the most common cause of abdominal trauma. Liver injury is
often found in cases of abdominal trauma, sometimes accompanied by injury to other organs
such as the spleen. This case presents liver and spleen trauma and its management based on the
patient's clinical condition.
Case: In this case, a 31-year-old man came to the emergency room after a vehicle accident. A
primary survey found ineffective breathing problems. A physical examination revealed limited
chest movement, tenderness in the chest, and bruising. During observation, the patient's
condition then worsened with a marked decrease in blood pressure and oxygen saturation, with
ultrasound results showing free intra-abdominal fluid, which indicated intraabdominal
haemorrhage. An exploratory laparotomy operation was immediately carried out when a grade V
splenic rupture and laceration of the liver was found. The surgeon then decided to perform a
laparotomy to control the bleeding, repair the left lobe of the liver, and splenectomy to evacuate
the organ.
Conclusion: Some guidelines recommend a non-operative management approach in cases of
abdominal trauma. However, if conditions where organ damage and unstable hemodynamics
occur, operative management is the best option.
Keywords: abdominal trauma, blunt trauma, liver rupture, spleen rupture, traffic injury
Background
Abdominal trauma contributes to 20% of total traffic-related trauma cases in both adults
and children.1,2 Apart from traffic, falls are the other most common cause. This injury is
commonly found in work-related injuries in men.2 The majority of cases of abdominal trauma are
blunt trauma which can cause intra-abdominal bleeding. 1The mortality rate due to abdominal
trauma can range between 12.5-13.6%, with no significant difference between men and women. 2
Abdominal trauma cases are more common in young adults between 26 – 70% compared to all
age groups.1,2 The liver is one of the organs most affected by trauma along with the spleen, small
intestine, kidneys, and the retroperitoneum.1
On physical examination, abdominal pain, stiffness, and distension are generally found,
with some cases accompanied by other injuries such as the thorax and extremities. 3 Physical
examination is often unreliable because during treatment in the emergency room, doctors are
generally concerned about life-threatening injuries such as head and chest injuries. 3 At the same
time, the onset of abdominal trauma often appears delayed. 1,3 Missed intra-abdominal organ
injuries will increase patient morbidity and mortality, especially after the patient survives the
initial phase of post-accident injury. In addition, children have anatomically and physiologically
immature organs, so injury examination may be missed due to a lack of physician's experience. 4
Generally, intra-abdominal injuries do not require operative management as the quality of non-
operative management increases which reduces the risk of mortality, but in some conditions,
operative management is required.5 In this case, we present liver and spleen trauma resulting
from a motorbike accident and its management according to the patient's clinical condition.
Case description
A 31-year-old man came to the emergency room with complaints of shortness of breath
and chest pain after a motor vehicle accident 30 minutes before admission, and did not remember
the incident. The patient was previously unconscious after the accident, but when he arrived at
the hospital the patient regained consciousness. In the primary survey, no airway problems were
found with ineffective breathing patterns due to chest pain. Glasgow Coma Scale 15 with vital
signs blood pressure 103/79 mmHg, heart rate 91 bpm, respiratory rate 20x/minute, temperature
360C, and oxygen saturation 96% without supplementation. In the secondary survey, a 4 x 5 cm
reddish wound was found in the sternum area, limited chest movement, pain on palpation, and
lacerations on several parts of the body.
During 30 minutes of observation, vital signs worsened with a decrease in blood pressure
of 50/30 mmHg, an increase in heart rate of 130 bpm and respiratory rate of 26x/minute, and a
decrease in oxygen saturation of 84%. The results of the ultrasound examination showed free
intraperitoneal fluid around the liver, spleen, and pelvic cavity. The spleen is enlarged with an
inhomogeneous echo-structure, the capsule edge is not intact. The kidneys show normal echo-
structure, the border between the cortex and the medulla is clear, the pelvicalyceal system is not
widened (Figure 1). A CT-Scan examination was not carried out considering that the patient's
hemodynamic condition was unstable. The patient was then given resuscitation with 2000 cc of
RL, citicoline, tranexamic acid, and antibiotics, and a catheter was installed.
Figure 1. FAST Ultrasonography Results show free fluid in the intraperitoneum between the
liver, spleen, and pelvic cavity. FF = Free fluid, RL = Right liver, LL = Left liver, RS = Left
kidney, AO = Aorta abdominal, VF = vesica fellea, VU = vesica urinaria, BC = blood clot.
The patient was immediately planned for an immediate exploratory laparotomy to stop
internal bleeding. On intraoperative findings, a hematoma surrounded the right kidney. After the
blood was suctioned, it was found that the left liver lobe had ruptured, damaging the capsule and
cortex. So it was decided to perform resection of the spleen (Figure 2), and repair the left lobe of
the injured liver. The working diagnosis in this case is liver and spleen rupture post exploratory
laparotomy for indications of intra-abdominal bleeding caused by blunt trauma with retrograde
amnesia due to moderate head injury.
A B
Figure 2. Gross examination of the spleen from anterior (A) and posterior (hilus) (B) view after
resection
Discussion
The liver is the abdominal organ most commonly affected by trauma, either due to blunt or
penetrating trauma which can injure the parenchyma and major blood vessels. 6 Blunt trauma is
the most common cause, where liver injury arises from strong acceleration followed by
deceleration in an accident, which then results in laceration of the main hepatic vessels or lobes
after acceleration and parenchymal laceration both anteriorly and posteriorly during
deceleration.7 This condition can arise due to the liver structure not being fixed by ligaments so
the liver can have lacerations due to interaction with surrounding organs. 7 Rib fractures,
pneumothorax, and renal injuries are often associated with liver injury. 7 The liver is also an
organ with various types of vasculature ranging from large arteries to small vessels causing it
easy to bleed. Bleeding from liver injury contributes to a 10 – 15% mortality rate in cases of
severe abdominal trauma.8
Clinical manifestations of liver injury due to blunt trauma are often delayed. 50 - 85% of
patients often come to the ER in a stable hemodynamic condition. In liver injury with
hemorrhage, right quadrant abdominal rigidity, distension, and hypotension often lead to
hypovolemic shock.8 Diagnosis of liver trauma is determined from hemodynamic status and
imaging examination with Extended-focused abdominal sonography for trauma (E-FAST) for
detection of free abdominal fluid and Computed tomography (CT) scan with intravenous
contrast.5 CT-scan is recommended as the gold standard in stable hemodynamic conditions. If
resources do not allow, Diagnostic peritoneal lavage (DPL) can be used to find free peritoneal
fluid with stable hemodynamics or when the patient is in shock and ultrasound is not possible. 5
In this study, E-FAST was useful when worsening of the patient's hemodynamics was found
during the observation process which determined further management.
The diagnosis of liver trauma is based on physical and imaging findings. The World
Society of Emergency Surgery (WSES) ranks based on the American Association for the
Surgery of Trauma - American Association for the Surgery of Trauma-Organ Injury Scale
(AAST-OIS) and hemodynamic stability is minor (WSES grade I or AAST-OIS I- II), moderate
(WSES grade II or AAST-OIS III), and severe (WSES grade III or AAST-OIS IV-VI) which
also leads to unstable hemodynamics.5 In stable conditions, a CT-Scan examination is
recommended to determine the level of liver parenchymal or subcapsular damage depending on
the type of injury (laceration or hematoma).8 If hemodynamics is unstable, imaging examination
with E-FAST is recommended, although it can result in false negative results due to blood clots
or suboptimal viewing quality from ultrasound. 5 E-FAST is also useful before operative
management if the patient does not respond to hemodynamic resuscitation. 5 This grading is not
only useful as a determinant of diagnosis but also as a factor in determining prognosis and
predicting mortality.7
As many as 80% of blunt trauma cases undergo non-operative management. 8 A study by
Kumar et al (2021) shows that patients can be discharged for 48 hours of observation in the
hospital accompanied by periodic physical examinations every six hours during the first 24 hours
in the hospital.9 However, the sample in this study was mostly grade II-III organ injuries where
the condition was hemodynamically stable and the majority were accompanied by mild
hemoperitoneum.9 Also, nonoperative management requires radiological monitoring and regular
blood laboratory examinations.8 In the event that there is evidence of active extravasation,
pseudoaneurysm, or arteriovenous/arterioportal fistula from imaging examination, angiographic
management with embolization can be performed if the hemodynamic condition is stable with an
operator experienced in mesenteric catheterization and embolization. 6,8 This approach also
requires high costs because it requires a liquid embolization agent and operator experience to
avoid complications.6
In this patient, surgery was performed based on unstable hemodynamic indications during
observation. The main goal of operative management is to control bleeding either by simple
compression or suturing of the liver parenchyma if no major bleeding occurs or with vessel
ligation and balloon tamponade if major bleeding occurs. 5 Management of lobectomy and
splenectomy is increasingly rare but in cases with severe bleeding due to destructive injury that
damages >75% of one lobe, lobectomy can be performed. 10 The splenectomy approach itself is
more often avoided because it has a higher mortality rate than embolization or nonoperative
management.11 However, management decisions need to be made according to the patient's
clinical condition intraoperatively while controlling bleeding.7
Conclusion
Abdominal trauma requires attention to internal bleeding which can be life-threatening.
Although there are many reports describing abdominal trauma of either the spleen or the liver,
the simultaneous trauma of both organs is a rare event. A clinician must consider the entire
clinical scenario to decide between the operative or nonoperative management. Operative
management is needed in unstable hemodynamic conditions to control bleeding and evacuate
damaged organs.
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