A 16-year-old boy is brought to the emergency department due to severe abdominal pain. He was playing soccer an hour ago when he suddenly developed left upper quadrant pain. The pain is sharp and constant and makes it difficult for him to take deep breaths. The patient has been otherwise healthy except for several days of fever, sore throat, and fatigue 2 weeks ago. He takes no daily medications, and immunizations are up to date. Temperature is 37.2 C (99 F), blood pressure is 86/58 mm Hg, pulse is 122/min, and respirations are 24/min. Pulse oximetry is 96% on room air. Physical examination shows an uncomfortable-appearing adolescent. The lungs are clear to auscultation, and heart sounds are normal. The abdomen is soft, with left upper quadrant rebound tenderness. Which of the following is the best next step in management of this patient?

Question

A 16-year-old boy is brought to the emergency department due to severe abdominal pain.  He was playing soccer an hour ago when he suddenly developed left upper quadrant pain.  The pain is sharp and constant and makes it difficult for him to take deep breaths.  The patient has been otherwise healthy except for several days of fever, sore throat, and fatigue 2 weeks ago.  He takes no daily medications, and immunizations are up to date.  Temperature is 37.2 C (99 F), blood pressure is 86/58 mm Hg, pulse is 122/min, and respirations are 24/min.  Pulse oximetry is 96% on room air.  Physical examination shows an uncomfortable-appearing adolescent.  The lungs are clear to auscultation, and heart sounds are normal.  The abdomen is soft, with left upper quadrant rebound tenderness.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient's sudden, severe left upper quadrant pain and signs of hypovolemic shock (eg, hypotension, tachycardia) 2 weeks after an episode of pharyngitis are most concerning for spontaneous splenic rupture, a life-threatening condition that can occur in the setting of postviral splenomegaly. Viral infections, especially Epstein-Barr virus (ie, infectious mononucleosis) and cytomegalovirus, are among the most common causes of splenomegaly in children and adolescents. Splenomegaly occurs due to lymphocytic infiltration into the spleen; the infiltration disrupts the spleen's fibrous support system and stretches the spleen's capsule, increasing the risk of splenic rupture. Affected patients are advised to refrain from sports for several weeks; however, even when appropriate precautions are taken, rupture can be spontaneous and atraumatic. Management of splenic rupture begins with resuscitation and stabilization of the patient. Hypovolemic shock, as seen in this patient, requires immediate volume resuscitation (eg, crystalloid, blood products). Once the patient is hemodynamically stable (eg, systolic blood pressure >90 mm Hg), a CT scan of the abdomen with intravenous contrast may be performed to assess the severity of splenic injury and determine whether bleeding is ongoing (ie, contrast extravasation) (Choice A). Patients with spontaneous splenic rupture should ideally be managed nonoperatively (eg, observation with serial hemoglobin measurement, embolization) to preserve splenic function. However, patients who remain hemodynamically unstable despite adequate resuscitation (eg, due to severe ongoing hemorrhage) may require exploratory laparotomy and splenectomy (Choice C). (Choice B) Diagnostic peritoneal lavage (DPL) was historically used to evaluate for intraabdominal hemorrhage in certain hemodynamically unstable patients. However, DPL is more invasive and less informative than a CT scan (eg, DPL cannot identify the specific bleeding source or differentiate ongoing vs recent bleeding), and this patient may be stable enough to undergo CT scan following volume resuscitation. Diagnostic peritoneal lavage (Choice D) Monospot testing (ie, heterophile antibodies) can be used to confirm the diagnosis of infectious mononucleosis but would not alter the immediate management of this patient with splenic rupture and subsequent hypovolemic shock. Educational objective: Viral infection (eg, Epstein-Barr virus) can cause splenomegaly, which increases the risk of splenic rupture. Splenic rupture can cause intraabdominal hemorrhage and hypovolemic shock; volume resuscitation is the first step in management. References: Splenic rupture in infectious mononucleosis: a systematic review of published case reports. (http://www.ncbi.nlm.nih.gov/pubmed/26563483) Spontaneous splenic rupture in infectious mononucleosis: case report and review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/23222107)

A 16-Year-Old Boy Is Brought to the Emergency Department Due