Splenic rupture in a patient with situs inversus
A 20-year-old lady presented to the emergency room with complaints of pain in the right lower chest and right upper abdomen, after being kicked in the chest by a horse few hours back. Her abdominal pain soon became generalized and she also complained of increased chest pain during inspiration. She gave no history of vomiting. On initial examination, she had tachycardia (98 beats per minute) and her blood pressure was 100/80 mmHg. Her respiratory rate was 20 per minute and decreased breath sounds were present on the right side. A bruise could be seen over her right lower chest and upper abdomen. Her abdomen was tense, tender and distended with absent bowel sounds. A provisional diagnosis of chest injury with liver injury following blunt trauma abdomen was made and resuscitation was started. Two large bore intravenous lines were secured and patient was given Ringer lactate solution. A Foley's catheter was introduced to assess the response to resuscitation.\nA chest X-ray revealed the heart to be normal in position (apex on the left side) along fractures of the ninth and 10th ribs on the right side. There was no evidence of haemo-pneumothorax or any other bony injury on the X-ray (). An ultrasound of the abdomen revealed moderate amount of free fluid in the abdomen with an injured spleen present in the right hypochondrium. Computerized tomography (CT) scan of the abdomen revealed a shattered spleen on the right side with a normal liver and gall bladder on the left side (). The rest of the abdominal viscera appeared to be normal.\nIn view of the altered haemodynamic status of the patient, a decision was taken to carry out an emergency exploratory laparotomy. During laparotomy, 1.5 L of blood was evacuated from the peritoneal cavity and a shattered spleen was seen in the right hypochondrium with active bleeding. The splenic pedicle was intact and an emergency splenectomy was carried out. The liver and the other viscera were reversed in position but normal. The postoperative period was uneventful and the patient was discharged on the sixth postoperative day. Prior to discharge, the patient was immunized against Pneumococcus, Meningiococcus and Haemophilus influenzae.