Presented by: Mark Noble MD
Cleveland Clinic

Introduction

Major hemorrhagic complications after left extracorporeal shockwave lithotripsy (ESWL) are quite rare.  We present a 33-year old patient who developed the very unusual outcome of a large splenic hemorrhage and hemoperitoneum after left ESWL for a non-obstructing 0.9 cm mid-renal stone. We discuss our management experience with this very rare event and contrast our experience with the few, other such reports in the medical literature.

Materials

A 33-year old male with history of Gilbert syndrome was evaluated for 3 weeks of intermittent left flank pain.  An abdominal CT showed a 0.9 cm non-obstructing left mid-renal stone (HU 1400) with a skin-to-stone distance of 6.4 cm. Pre-operative lab work was otherwise normal. The patient was offered left ureteroscopy with laser lithotripsy and extracorporeal shockwave lithotripsy (ESWL) and elected to proceed with ESWL.  A Dornier Delta III lithotripter was used (2500 shocks, 60 shocks per minute, 1 to 7 mAmp), and good dispersion of the stone was noted on fluoroscopy during the procedure.

Results

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Twelve hours post-operatively, the patient developed abdominal pain followed by a syncopal episode necessitating travel to the nearest emergency room. The patient was tachycardic to 112 but hemodynamically stable on admission, with mean arterial pressures in the high 80s. Exam was significant for guarding and left flank tenderness. Hemoglobin was 8.6 from pre-operative 15.1 g/dL, and FAST revealed hemoperitoneum. A CT scan was performed (Figure 1). Although perinephric hematoma from ESWL is not uncommon (1-25%), extra-renal injuries are exceedingly rare, with only ten other case reports of splenic rupture identified in the medical literature.  All reported splenic injuries were from left-sided ESWL with the most common clinical presentation being progressive abdominal pain and hypotension. All patients in these reports underwent splenectomy. Our scenario was uniquely amenable to angiography given the isolated nature of the splenic injury and the patient’s hemodynamic stability.

Conclusion

Acute care surgical guidelines for blunt splenic injuries recommend non-operative management if hemodynamically stable and without peritonitis, laparotomy if both hemodynamically unstable and with peritonitis, and angiography with embolization if hemodynamically stable but with grade III+ injury, contrast blush, moderate hemoperitoneum, or ongoing bleeding. Because many urologists who routinely perform ESWL for treatment of nephrolithiasis are not aware of splenic rupture as a possible complication, we wish to relate that in patients presenting with syncope or abdominal pain after left-sided ESWL, splenic parenchymal or vascular rupture should be considered and treated according to acute care trauma guidelines.

Funding

None

Lead Authors

Paul Oh, MD
Cleveland Clinic

Co-Authors

Madison Lyon, MD
Cleveland Clinic

Scott Lundy, MD, PhD
Cleveland Clinic