LAUSR

We present an athletic 21-year-old male, who was admitted to a tertiary referral hospital with severe upper abdominal pain following a direct blunt force injury to the abdomen whilst playing rugby. The only significant history was a similar presentation to a rural hospital 12 months prior to this admission. Computed tomography (CT) imaging at the time reported an inferior splenic laceration with a 102 × 77 mm subcapsular haematoma (Fig. 1a,b) which was managed non-operatively and the patient was subsequently lost to follow-up and had no further symptoms or imaging. Otherwise, he had no other co-morbidities or regular medications, nor was there any significant family history. On presentation to the emergency department, he had normal vital signs and a soft abdomen on examination with left upper quadrant tenderness. An abdominal CT scan with oral and intravenous contrast revealed a small-volume haemoperitoneum, a 40 × 35mm splenic laceration which extends into a cystic lesion 60 × 45 × 35 mm, as well as a second 125 × 75 × 75 mm cyst (Fig. 1c,d) but no contrast extravasation to suggest active haemorrhage. During admission, he was managed non-operatively. His vital signs remained normal, pain was adequately controlled with simple analgesia and haemoglobin remained stable above 130 g/L. Although he clinically appeared unchanged, a triple-phase abdominal CT scan on day 3 showed marginal increase in the dimensions of the splenic laceration and the abutting cystic lesion, now measuring 65 × 60 × 63 mm. Management options were discussed among consultant trauma surgeons, upper gastrointestinal surgeons and interventional radiologists. He was clinically stable and pain-free on day 6, and was discharged with the recommendation to avoid contact sports. An elective CT-guided percutaneous drainage of the larger pseudocyst was performed 3 months post-discharge. Approximately 500 mL of dark blood-stained fluid was aspirated with no complications. A subsequent percutaneous drainage for the second pseudocyst was planned; however, the patient was once again lost to follow-up. Splenic cysts are considered a rare phenomenon following blunt traumatic injury, and may be asymptomatic in up to 60% of patients. They are more correctly defined as ‘pseudocysts’ due to the lack of a true epithelial lining which is seen in the more common parasitic cysts. The management of traumatic pseudocysts of the spleen may be divided into four categories: observation, percutaneous drainage, laparoscopic spleen-preserving procedures or splenectomy. Being extremely uncommon, there have been limited case reports and accordingly there are currently no evidence-based guidelines in adults. Furthermore, there have been no published cases regarding the management of patients with more than one splenic pseudocyst as in the case presented. Observation without any intervention for traumatic splenic pseudocysts allows for spontaneous involution. The exact size of pseudocysts amenable to this, and the time course required however is not well defined. This approach must be balanced against the potentially fatal risk of rupture. Based on a case series of seven patients, Pachter et al. estimated that traumatic pseudocysts greater than 5 cm have at least 25% risk of rupture and therefore require some form of intervention. In another case series of four traumatic