Abdominal pain is a main manifestation of delayed bleeding after splenic injury in patients receiving non-operative management

This retrospective study analysed our experience with the management of delayed bleeding complications of high-grade blunt splenic injury after NOM. Seventeen of 138 (12.3%) high-grade splenic injuries required salvage procedures following NOM. Eleven and six patients were successfully salvaged by repeat SAE and splenectomy, respectively. Abdominal pain was the main manifestation of delayed bleeding for patients following discharge from the ICU. This is an important early warning sign of delayed bleeding from a splenic injury, especially as the patient leaves the hospital. To the best of our knowledge, few studies have reported on bleeding complications of splenic injury after NOM; these studies include 17 cases with delayed bleeding complications, only two of which included > 10 cases14,17. The current study demonstrated that abdominal pain is an important warning sign of delayed bleeding of splenic injury, especially in patients discharged from the ICU; this is an important manifestation that has rarely been emphasised in the literature.

Arterial embolization has been widely used for solid organ injury and can significantly increase the success rate of NOM for spleen injury10. According to recent studies, SAE resulted in > 90% success rate of NOM3,4. However, SAE could not totally prevent delayed bleeding episodes in patients receiving NOM. Approximately 17–25% of patients with splenic injuries had bleeding episodes after SAE9. Failure of NOM resulted in higher rates of mortality or prolonged hospitalisation14. However, there were no differences in the success rate of NOM or incidence of adverse events between patients who received prophylactic SAE and those who received indicated SAE3. In the current study, 17 of 138 (12.3%) patients needed salvage procedures after the initial NOM. Close monitoring of the signs and symptoms of bleeding is crucial for patients receiving NOM to detect bleeding episodes early and avoid unfavourable outcomes.

Delayed diagnosis of bleeding episodes can be dangerous or even deadly. Peitzman et al. reported 10 mortalities among 78 splenic injury patients with NOM failure4,14,15,18, and a 5–15% mortality rate have been reported by other studies18,19,20. Romeo et al. reported two cases of delayed splenic bleeding presenting with haemorrhagic shock, who were then admitted for several months21. Kodikara also reported a death due to delayed splenic rupture-related haemorrhagic shock22. Delayed bleeding episodes may result in acute haemodynamic instability, which significantly increases morbidity and mortality and is a risk factor for the development of multiple organ dysfunction23.

Most delayed bleeding episodes after the splenic injury occurred in the early period of NOM. Studies showed that 80–95% of splenic injuries had delayed bleeding episodes within 72 h of injury, and 18% of patients had failed NOM longer than 5 days after admission4,14,24. Thus, patients with high-grade splenic injury require close observation by real-time monitoring in the ICU. In our protocol, the patients were observed in the ICU for 24–48 h with regular monitoring of haemoglobin levels every 6–8 h after SAE. The bleeding episodes in our study occurred from 8 to 28 days after the start of NOM. Among patients who had bleeding episodes, 11 (64.7%) experienced them within 5 days, and 15 patients (88.2%) within 2 weeks of the injury. Several studies have suggested that longer observation periods should be adopted, but the need for observation eventually ended in up to 80% of patients within 14 days and in 95% within 21 days24,25,26,27. Ten (58.9%) patients experienced bleeding episodes in the ICU, while seven (41.2%) patients experienced bleeding episodes in the ward or at home. Most of the patients were discharged within one week. Prolonged observation in hospitals may not be practical and could waste medical resources. Accordingly, educating patients and their families about early signs of bleeding is relevant and crucial.

Abdominal pain may be a reliable manifestation of delayed bleeding in patients receiving NOM. In 1977, Olsen et al. demonstrated ten cases of delayed splenic rupture and showed that most of them experienced abdominal pain in different durations, patterns, and severity17. Farhat reported one case of delayed splenic rupture and mentioned that abdominal pain was common28. Peitzman et al. reported 78 cases of splenic injury with NOM failure, and the presentations of delayed bleeding in their study included haemodynamic decompensation (15%), decreased haemoglobin (36.5%), new abdominal pain (5%), worsening of abdominal pain (36.5%), and persistent tachycardia (16.2%)14. These were comparable with our results. According to the literature and our experience, the pattern of pain involved sudden onset of severe pain over the upper-left quadrant area29. Additionally, our study demonstrated that the main manifestations of delayed bleeding changed at different time periods (in the ICU, the ward or at home). Decreased haemoglobin levels were the main manifestation in patients requiring a salvage procedure in the ICU. However, new abdominal pain was the main presentation (71.4%) when a bleeding episode happened in the ward or at home. Only approximately one-third of patients with delayed bleeding had hypotension. For this reason, focusing on the signs of haemodynamic status may overlook patients with delayed bleeding. Here, three patients with delayed bleeding were unnoticed in the emergency department when they returned after discharge as they presented with symptoms of sudden abdominal pain rather than hypotension or a decline in haemoglobin levels. Recognising abdominal pain as one of the main presentations of delayed splenic bleeding is crucial for early diagnosis to avoid unfavourable outcomes. Additionally, Kofinas et al. mentioned the pattern of pain was left lower thorax and upper abdominal pain or tenderness in 202129. It a similar clinical case of delayed splenic rupture, in which a young female received non-operative treatment initially similar clinical situation. Similarly, sudden onset of severe abdominal pain at left upper quadrant was the common pattern in our experience.

Currently, no definitive guidelines have been established for identifying delayed bleeding following a splenic injury that has been treated with NOM. The World Society of Emergency Surgery classification of splenic trauma and the management guidelines are evidence-based2 and recommended angiography, angioembolization, and splenectomy as salvage strategies for bleeding after NOM based on different indications. Operative management should be applied in cases of haemodynamic instability or if associated intra-abdominal injuries requiring surgical treatment are present30. The use of SAE for delayed splenic bleeding is supported by some evidence, for example, Liu et al. reported that five of six patients with delayed splenic bleeding were successfully salvaged by SAE31. Here, 17 of 138 (12.3%) patients received NOM for high-grade splenic injury and later needed salvage procedures, and 11 of the 17 patients with delayed bleeding were successfully salvaged by repeat embolization. Repeating SAE for selected patients with delayed splenic bleeding is a safe and feasible strategy.

The current study has several limitations. First, this was a retrospective study, and the patients’ symptoms and haemodynamic data were collected by reviewing their electronic medical records. Symptoms of abdominal pain could have been overlooked and incompletely recorded. However, haemodynamic data such as hypotension were less likely to be missed. Nevertheless, this did not affect our conclusion that abdominal pain was the main manifestation of delayed bleeding following discharge from the ICU. Second, some patients with delayed bleeding may have received treatment at other hospitals. We believe this probability to be low because most patients with a high-grade splenic injury received follow-up at our outpatient department, and it may not have affected the results of the current study. Third, the sample size was small as most previous studies were case reports. Only one study had more cases of delayed bleeding than the current study. Fourth, we frequently checked haemoglobin levels in the ICU and identified patients with signs of bleeding while the haemodynamic status was stable. Angiography usually shows oozing of the contrast in the spleen parenchyma. This type of bleeding may stop spontaneously, and our protocol may increase the incidence of delayed bleeding. However, the bleeding episodes only accounted for 12.3% of all the high-grade splenic injuries receiving NOM, which was not higher than that observed in previous studies4,6,9,14,31.

Delayed splenic bleeding is unpredictable and may occur within 4 weeks of the injury. The common clinical manifestations of delayed splenic bleeding include tachycardia, hypotension, a decline in haemoglobin levels, and abdominal pain. Abdominal pain is the main early clinical presentation of delayed bleeding after a patient leaves the ICU and hospital, and this is the first study to highlight its importance as an early clinical manifestation of delayed bleeding. Emphasising the importance of abdominal pain as an alarming presentation of delayed bleeding can help patients determine when to return to the hospital for timely management.

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