A 22 year old male presents 1 week post football injury to his left upper quadrant. He complains of abdominal pain, presyncope on standing and is pale and tachycardic although maintaining a normal blood pressure.
Describe and interpret these scans
Image 1: RUQ: There is a large amount of free fluid in the right upper quadrant.
Image 2: LUQ: The normal outline of the usually homogeneous spleen is completely lost. Instead a heterogeneous disorganized predominantly echogenic collection of blood clot is seen.
Image 3 and 4: Pelvis: Views of the pelvis show free fluid. The fine echogenic particulate appearance is typical of blood that has not yet formed clot nor layered. Imagine an ESR tube with red cells slowly settling with gravity.
Haemoperitoneum with splenic rupture.
This patient had a normal EFAST at his initial presentation – the spleen appeared normal and there was no free fluid. He was considered low clinical risk of significant injury, was observed, and then discharged with advice to return in he had problems.
It is extremely important to understand that solid organ injuries may be missed acutely with ultrasound. In this case echogenic acute blood clot filled the splenic laceration and the subcapsular haematoma had the same echogenicity as the spleen – and it was not seen. As the injury was initially contained there was no free fluid.
Delayed presentation with haemorrhage from a splenic injury is well recognised and occurred in this case.