Ongewone oorzaak van hemodynamische shock Philippe Bernard - Radiologie Katrien Baggerman - Urgentiegeneeskunde
Huidige problematiek Vrouw, 81 jaar Verwezen wegens hypotensie en bleekheid Moe, anorexie Pijn linkerhypochonder/fossa, diarree Nausea
Medische voorgeschiedenis MDS VKF waarvoor 2x electr. reconversie 2/2012: Folliculair lymfoom (halsklier) 2/2012: Longadenoca.
Huidige R/ Apocard Aldactazine Emconcor Plendil Marevan Fosamax Iressa
Klinisch onderzoek bij opname Bleek BD 90/50 mmhg, pols 78 bpm, Sat 94%, Temp 36.3 C Cor en longen: gb Abdomen: opgezet, drukpijnlijke linker hypochonder zonder prikkelingstekens
CRP + 2.6 mg/dl < 0.50 Hemoglobine - 8.2 g/dl 12.0-16.0 Hematokriet - 25.4 % 37.0-47.0 Rode bloedcellen - 2.57 x10*6/µl 3.90-5.60 MCV + 99 fl 78-98 MCH 32 pg 27-34 MCHC 32 g/dl 31-35 Labo resultaten Witte bloedcellen + 17.3 x10*3/µl 4-10 Thrombocyten - 121 x10*3/µl 150-400 PT (%) - 6 % 70-150 INR + 6.8 ratio < 1.4 Natrium - 135.9 mmol/l 136.0-145.0 Kalium 4.3 mmol/l 3.5-5.1 Chloride - 96 mmol/l 98-107 Bicarbonaat 24.1 mmol/l 22.0-31.0 Anion gap + 20 mmol/l 10-19 Glucose + 179 mg/dl 60-100 Kreatinine + 2.01 mg/dl < 0.90 Ureum + 60 mg/dl 21-43 Urinezuur + 10.1 mg/dl 2.3-6.1 Totaal eiwit (oude eenh) - 6.0 g/dl 6.4-8.3 Bilirubine totaal 0.6 mg/dl < 0.9 Bilirubine direct/geconjugeerd + 0.3 mg/dl < 0.2 CK 20 U/L < 170 ASAT (GOT) 20 U/L < 31 ALAT (GPT) 10 U/L < 33 LDH 334 U/L < 480 Gamma GT 23 U/L < 36 Alkalische fosfatase 75 U/L < 104 Amylase...(8) U/L < 100 Lipase 27 U/L < 60
Differentieel diagnose linkerhypochonder Pancreatitis Pneumonie Cardiale ischemie Maaglijden Nierkoliek Miltinfarct/-abces
Atraumatische Milt Ruptuur (ASR) spontaan, pathologisch, occult = zonder (excessieve) externe kracht Uitlokkende factor : hoest, val Zeldzaam, vaak gemist
Oorzaken 1. Neoplastisch 2. Infectieus 3. Inflammatoir, niet-infectieus 4. Medicamenteus- en behandelings-gerelateerd 5. Mechanisch 6. Idiopathisch (normale milt)
Neoplastic disorders Malignant haematological disorders Acute myelogenous leukaemia Acute lymphoblastic leukaemia Various leukaemia Hodgkin s lymphoma Non-Hodgkin s lymphoma Myeloproliferative disorders Myelodysplastic syndromes Non-malignant haematological disorders Histiocytosis Idiopathic thrombocytopenic purpura Various Primary neoplastic disorders Angiosarcoma Peliosis Cystic lesions Haemangioma Various Secondary metastatic neoplastic disorders Choriocarcinoma Lung cancer Melanoma Various Infectious disorders Viral infectious disorders Infectious mononucleosis Cytomegalovirus infection Human immunodeficiency virus infection Dengue fever Various Bacterial infectious disorders Endocarditis Q fever Tuberculosis Typhoid fever Various Protozoal infectious disorders Malaria tertiana (Plasmodium vivax) Malaria tropica (Plasmodium falciparum) Various Fungal infectious disorders Aspergillosis Inflammatory, non-infectious disorders Local inflammatory and neoplastic disorders Chronic pancreatitis Acute pancreatitis Pancreatic cancer Various Amyloidotic disorders Primary amyloidosis Secondary amyloidosis Various Vascular disorders Wegener s granulomatosis Polyarteritis nodosa Various33, Genetic disorders Haematological disorders Storage diseases Autoimmune disorders Rheumatoid arthritis Systemic lupus erythematodes Various Drug- and treatment-related disorders Drug-related splenic rupture Granulocyte colony-stimulating factor8, Anticoagulation5, Thrombolytic therapy Various Dialysis-related splenic rupture Haemodialysis Continuous ambulatory peritoneal dialysis Mechanical disorders Pregnancy-related splenic rupture During pregnancy During labour and postpartum Postcaesarean section Intrasplenic pregnancy Congestive splenomegaly Liver cirrhosis (portal hypertension) Hepatic inflow occlusion (Pringle manoeuvre) Normal spleen
Beeldvorming Echografie: Intraperitoneaal vocht/bloed Splenomegalie (> 5 x 11 cm) Focale letsels miltscheur/-laceratie lymfoom, metastase, infarct,. Vaak onderschatte letsels Tot 50%
Beeldvorming Computed Tomography: Meer accurate visualisatie van miltletsels geassocieerde letsels Etiologie Gradatie (AAST)
AAST-classification American Association of Trauma, 1994 III IV
Beleid initieel conservatief gezien verdere hemoglobine- en bloeddrukval: splenectomie
Besluit atraumatische miltruptuur -> onderliggende pathologie? shock bij onderliggende pathologie -> spontane miltruptuur?