Jack was a reluctant patient. At 16, he was clearly not happy at his mother insisting he should come to see me for what he considered to be a minor injury.
'He got hit by a hockey ball on Saturday,' she said, 'and is still complaining three days later.'
'I'm all right, Mum,' said Jack. 'My mates will think I'm a wimp. I ought to be at school.'
His mother disagreed. 'He has been lying around holding his side and moaning, and has not been eating properly.'
I tried to make light of Jack's situation but insisted he tell me the whole story. He said that he had tried to block a long pass, but the ball flew up and hit him in his ribs as he turned sideways.
'It really hurt,' said Jack. 'But I managed to carry on,' he added with a hint of pride.
Sporting injuries: blunct trauma may resukt in internal damage
Jack showed me the typical signs of a high-energy impact with a ball - a large, red, circular weal with a pale centre. It was in the mid-axillary line and just over his lower ribs. The area was very tender and when I asked Jack to get on the couch, it was clearly a bit of a struggle.
His abdomen was soft, although there was some tenderness when I pushed over the left hypochondrium. I thought it might be a cracked rib and was about to reassure his mother when I thought to ask if he had pain anywhere else.
'Well, my left shoulder hurts a bit,' he volunteered.
Jack had a full range of painless movement in his shoulder, but when he slowly rose from the couch he clutched his shoulder and said: 'It hurts when I move.'
I decided then that I should send him to A&E. His mum gave an 'I told you so' look, but I was clearly not Jack's best friend.
However, he was much happier with me the next time I saw him, when he proudly showed me his splenectomy scar. The hospital report informed me that he had had an ultrasound scan that showed fluid in the spleno-renal space.
His BP dropped after the scan, so a central line was put in and he was taken to theatre. A considerable amount of blood was found in the peritoneal cavity and a ruptured spleen was removed.
The spleen is the most commonly injured abdominal organ in blunt trauma, followed by the liver. Apart from obvious trauma such as RTAs, physical assault and sports injuries, sometimes even minor trauma can cause splenic rupture in patients with a pre-existing splenomegaly, such as may occur in infectious mononucleosis, malaria and leukaemia.
Patients with glandular fever should be warned about avoiding contact sports until recovery is complete and any splenomegaly has resolved.
Splenic rupture may present with isolated left upper quadrant pain, diffuse abdominal tenderness and sometimes, as in this case, pain in the left shoulder due to irritation of the diaphragm by blood. This shoulder pain is called Kehr's sign.
Risk of infection
Patients who have undergone splenectomy are susceptible to overwhelming infections, so they should be given specific vaccinations and have long-term antibiotic prophylaxis.
The latest guidelines1 state that all splenectomised patients should receive pneumococcal, haemophilus influenzae type B and meningococcal group C conjugate vaccines. Influenza jabs should also be given.
Lifelong prophylactic oral antibiotics, with either penicillin V or erythromycin, are recommended.
Among other recommendations, splenectomised patients should be given written information and carry an alert card or bracelet to show health professionals, and be educated about the potential risks of overseas travel, particularly regarding malaria and unusual infections.
Patient records should be clearly labelled, and vaccination and re-vaccination status clearly documented.
There is some evidence that primary care falls short of implementing these guidelines.2 A study in Scotland found that recommended vaccinations were only being received by 52 per cent of at-risk patients, and not many more were given appropriate prophylactic antibiotics.
After my encounter with Jack, we carried out a review of our splenectomised patients and ensured that we were meeting the guidelines.
- Dr Barnard is a former GP in Fareham, Hampshire
1. Davies JM, Barnes R, Milligan D. Update of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. J R Col Physicians Lond 2002; 2(5): 440-3.
2. Kyaw MH, Holmes EM, Chalmers J et al. A survey of vaccine coverage and antibiotic prophylaxis in splenectomised patients in Scotland. J Clin Pathol 2002; 55: 472-4.