Case study - A confusing presentation of abdominal pain

It is extremely important to carefully assess patients with pre-existing conditions, says Dr Srishti Dutta.

Ruptured spleen: large extravasations of blood can be life-threatening
Ruptured spleen: large extravasations of blood can be life-threatening

Mr F was a 70-year-old with diabetes mellitus and a number of cardiovascular problems including mild aortic stenosis, mild concentric left ventricular hypertrophy, coronary artery bypass grafts and AF.

He was complaining of left-sided abdominal pain for two days. He indicated his left flank as the site of the pain, and said it was worse when he moved.

He was also complaining of nocturia, urgency and frequency, but no dysuria.

We were already investigating persistent tiredness he had been experiencing, and a recent blood test showed a normal FBC, but his glycaemic control was poor. Because of this, we had advised Mr F to add glipizide to the metformin he was already taking. At the same time he had started warfarin because of his AF.

On examination there was mild left renal angle tenderness, and a urine dipstick analysis showed leucocytes, protein, blood and glucose.

He was afebrile and his BP was 156/90 mmHg. This all seemed to point to a UTI, so he was started on trimethoprim and advised to return if he was not improving in three days.

Worsening pain
Two days later, Mr F came back complaining that his left-sided abdominal pain was worse. He had also had a home visit the previous day from one of my colleagues who had prescribed diclofenac suppositories for suspected renal colic.

When I examined him again, I was concerned that his tenderness was more widespread, as it was now extending into the suprapubic area and the left hypochondrium. His BP was much lower, at 140/80, and alarm bells rang when he said he felt pain going to his left shoulder when he lay down.

I suspected an acute abdomen and told him I wanted to admit him to hospital. He refused, because it would mean leaving his grandson at home alone.

I was not happy with this, but he promised that he would call again if things became worse. This indeed is what happened later in the day and he was admitted as a matter of urgency.

After assessment by the surgical team, Mr F underwent an emergency splenectomy for a spontaneous splenic rupture of an enlarged spleen. The histology suggested a myeloproliferative disorder, but his FBC remained normal.

He is now awaiting bone marrow aspiration for a definitive diagnosis.

Diagnosis of splenic rupture
Upper abdominal pain is the commonest presenting symptom of traumatic or spontaneous rupture of the spleen.

It is usually worse in the left upper quadrant and is classically referred to the left shoulder, known as 'Kehr's sign'. Other clinical signs include hypotension, tachycardia and tenderness in left upper quadrant.

Signs of peritoneal irritation with guarding and rigidity may occur, usually due to extravasation of blood into the abdominal cavity. Investigations may show a drop in haemoglobin but this is not particularly helpful.

The diagnosis should be considered in patients presenting with left upper quadrant pain, even with no history of trauma.

Four criteria have been identified for the diagnosis of spontaneous splenic rupture.

These are: that there should be no history of trauma or of unusual effort which conceivably could injure the spleen; that there should be no evidence of disease in organs other than the spleen that might affect the spleen and predispose it to rupture; that there should be no evidence of perisplenic adhesions or scarring of the spleen to suggest previous trauma; and that the gross anatomy and histology of the spleen and clotting studies should all be normal.

A fifth criterion has since been added. This states that studies of acute-phase and convalescent sera should not show any significant rise in viral antibody titres suggestive of recent infection with viral types, such as Epstein-Barr virus, cytomegalovirus and hepatitis viruses.

  • Dr Dutta is a salaried GP in Hertfordshire
Learning points
  • Patients with multiple pathologies may present with new and unrelated problems that are easy to overlook.
  • Splenic rupture is associated with left upper quadrant pain.
  • Pain referred to the left shoulder is a classic sign.
  • Spontaneous rupture is a rare event, most cases are associated with trauma.

 

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