Patel VV. et al., 2020: A Case of Splenic Injury After Shockwave Lithotripsy Presenting as Septic Shock
Patel VV, Mohindroo A.
Community Medical Center, Toms River, New Jersey.
Background: Shockwave lithotripsy (SWL) is a common procedure, which can result in rare, life-threatening complications, such as splenic rupture, perinephric hematoma, sepsis, and ureteral colic from retained stone. Being able to identify these complications can result in successful diagnosis and expedited management.
Case report: We describe the case of an 82-year-old female presenting to the emergency department (ED) for hypotension and vomiting. The patient had undergone SWL for a kidney stone earlier in the day. On initial evaluation, the patient was hypotensive and reported mild abdominal pain. Although initially evaluated and treated for presumed sepsis, thorough testing was able to diagnose splenic rupture and hemoperitoneum. Splenic rupture is a rare complication of SWL and the patient's initial symptoms of hypotension and fever, with a potential source of infection, suggested a common presentation of sepsis and made this case a unique diagnostic challenge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Diagnosis is always a challenge in the ED, due to the variability of patients that can be seen. Often times, a patient's medical and surgical history will provide guidance. For this reason, it is important to know what complications exist with outpatient procedures, how they may present, and what patient risk factors may lead to an increased incidence.
J Emerg Med. 2020 Apr 27;S0736-4679(20)30152-9. doi: 10.1016/j.jemermed.2020.03.016. Online ahead of print. PMID: 32354591
The authors describe splenic rupture as complication to SWL. This is indeed a very unusual complication and I have not encountered this problem in any of the more than 20 000 treatments that I have witnessed.
The lesson learnt from this case report is that whenever a patient presents with unexpected clinical symptoms after SWL: always suspect bleeding complications!!! In this patient the first possible and likely diagnosis would have been the more common subcapsular renal haematoma. Therefore, always, and immediately order an NCCT! The conclusion that this patient had an infection complication should not be a reason for omitting search for bleeding.
In contrast to what usually is needed for patients with renal haematoma, those with splenic rupture need emergent surgical treatment.