Bleeding from Bare Area of Spleen Splenic Artery or Hepatic Artery

The hilum of the spleen receives the reflections of its supporting mesenteries, the gastrosplenic and spleno-renal ligaments (Fig. 8-97). The bare area of the spleen is the nonperitonealized area representing the fusion of the splenorenal ligament to the surface of the perirenal fat. It bears a constant relationship to the upper anterior part of the left kidney. Its length is usually about 2-3 cm, and its width is about 2 cm.130 The splenorenal ligament provides an anatomic bridge for bleeding to extend from the bare area of the spleen to the left anterior pararenal space51,130a (Fig. 8-98). In a review of CT scans in 23 cases with splenic trauma, hematoma in the left anterior pararenal space was seen in 3 (13%).131

The hepatic and splenic arteries are located anatomically within the anterior pararenal compartments. When these vessels rupture from trauma or aneurysm, the bleeding may be discretely localized to the extra-peritoneal space on the side of origin.

Bleeding from the hepatic artery is clearly shown in the following case history. A 70-year-old man was examined because of a 1 -month history of colicky right upper quadrant pain. His past medical history included acute rheumatic fever at the age of 5 and an episode of acute staphylococcal endocarditis at the age of 56. Oral cholecystography revealed moderate opacification of the gallbladder, and the hepatic angle, flank fat, and psoas muscle were clearly visualized (Fig. 8-99a) at this time. However, 24 hours later, the patient's colicky right upper quadrant pain increased suddenly, with abdominal distention. Initial diagnostic considerations included acute cholecystitis, acute pancreatitis, and penetrating peptic ulcer. An abdominal radiograph now showed a density throughout the right abdomen, with loss of the

Penetrating Gastric UlcerTeres Hepatis Ligament Lesion

Fig. 8-92. Cullen's sign secondary to spread of pancreatitis along falciform ligament.

(a-c) Inflammatory process of pancreas (P) has extended into the lesser omentum (LO) toward the liver and porta hepatis. There is extension of disease to the ligamentum teres as shown by increased density of fat in region (white arrow). Inflammatory densities extend throughout the falciform ligament and involve the properitoneal fat of the anterior abdominal wall (open arrow) immediately deep to the site of clinical periumbilical discoloration. Inflammatory changes consequent to the pancreatitis also involve the greater omentum lateral to the falciform ligament. Incidentally noted is mural thickening of the gallbladder. (a and c, reproduced from Meyers et al.24)

Fig. 8-92. Cullen's sign secondary to spread of pancreatitis along falciform ligament.

(a-c) Inflammatory process of pancreas (P) has extended into the lesser omentum (LO) toward the liver and porta hepatis. There is extension of disease to the ligamentum teres as shown by increased density of fat in region (white arrow). Inflammatory densities extend throughout the falciform ligament and involve the properitoneal fat of the anterior abdominal wall (open arrow) immediately deep to the site of clinical periumbilical discoloration. Inflammatory changes consequent to the pancreatitis also involve the greater omentum lateral to the falciform ligament. Incidentally noted is mural thickening of the gallbladder. (a and c, reproduced from Meyers et al.24)

hepatic angle, although the flank fat was clearly maintained (Fig. 8-99b). These changes indicated an acute fluid collection extraperitoneally, specifically within the anterior pararenal compartment. On the basis of these plain film abnormalities, a ruptured hepatic artery aneurysm was diagnosed radiologically. The patient's con dition deteriorated rapidly, however, and he died on the second hospital day. Postmortem examination revealed a 10-cm aneurysm involving the proximal hepatic artery and celiac axis (Fig. 8—99c), containing a laminated bland thrombus. Rupture had occurred with massive hemorrhage extraperitoneally on the right.

Pararenal Aneurysm

Fig. 8-93. Pancreatic extravasation with extension down the anterior pararenal space and then upward into the posterior pararenal compartment.

Sagittal diagram illustrates fluid collection in the left anterior pararenal space from the pancreas (P), and continuity under and around the cone of renal fascia into the posterior pararenal compartment. (Reproduced from Meyers.8)

Fig. 8-94. Perirenal fat involvement in acute pancreatitis.

Anterior pararenal space fluid has dissected posteriorly between the layers of the posterior renal fascia. Fluid collections are also present within the perirenal fat

(arrowheads).

(Courtesy of Michiel Feldberg, M.D., University of Utrecht, The Netherlands.)

Pseudocyst Rupture Intraperitoneal

Fig. 8-95. Perirenal pancreatic pseudocyst.

A huge pancreatic pseudocyst (Ps) distends the perirenal space posteriorly, displacing the kidney. Posterior renal fascia remains evident (arrow). Fluid from the cyst was aspirated, diluted X 120, and had an amylase content of 25,870 IU/L.

Splenic Pseudocyst Mri

Fig. 8-96. Subcapsular pancreatic pseudocyst of the kidney.

CT demonstrates a pseudocyst originating from the pancreatic tail entering the subcapsular space through the focally disrupted renal capsule. The pancreatic body and tail are shrunken and exhibit stones and dilated ducts.

(Reproduced from Blandino et al.120)

Spleen Bare Area

Fig. 8-97. Peritoneal attachments of the spleen.

(a) Transverse anatomic section demonstrates gastrosplenic ligament (GSL), within which course the short gastric and left gastroepiploic vessels, and the splenorenal ligament (SRL), which envelops the pancreatic tail and the proximal splenic vein (SV) and splenic artery (SA). Sp = spleen; ST = stomach; P = pancreas, DC = descending colon; LK = left kidney.

(b) Transverse drawing illustrates the intraperitoneal suspension of the spleen by the gastrosplenic and splenorenal ligaments.

Fig. 8-97. Peritoneal attachments of the spleen.

(a) Transverse anatomic section demonstrates gastrosplenic ligament (GSL), within which course the short gastric and left gastroepiploic vessels, and the splenorenal ligament (SRL), which envelops the pancreatic tail and the proximal splenic vein (SV) and splenic artery (SA). Sp = spleen; ST = stomach; P = pancreas, DC = descending colon; LK = left kidney.

(b) Transverse drawing illustrates the intraperitoneal suspension of the spleen by the gastrosplenic and splenorenal ligaments.

Spleen Ligaments

Fig. 8-98. Splenic bleeding extending through the splenorenal ligament to the anterior pararenal space.

Following a motor vehicle accident, peritoneal lavage showed no intraperitoneal blood in a patient with a falling hematocrit.

(a) CT demonstrates lacerations of the spleen extending into its bare area (arrows) with the blood within the left anterior pararenal space (asterisk).

(b) At the level of the kidneys, blood is evident within the anterior pararenal space extending to the descending colon (c) and posteriorly between the two lamellae of the posterior renal fascia.

(Courtesy of S. Balachandran, M.D., University of Texas Medical Branch, Galveston, TX.)

Fig. 8-98. Splenic bleeding extending through the splenorenal ligament to the anterior pararenal space.

Following a motor vehicle accident, peritoneal lavage showed no intraperitoneal blood in a patient with a falling hematocrit.

(a) CT demonstrates lacerations of the spleen extending into its bare area (arrows) with the blood within the left anterior pararenal space (asterisk).

(b) At the level of the kidneys, blood is evident within the anterior pararenal space extending to the descending colon (c) and posteriorly between the two lamellae of the posterior renal fascia.

(Courtesy of S. Balachandran, M.D., University of Texas Medical Branch, Galveston, TX.)

Bleeding from the splenic artery assumes a similar distribution, but a frequent associated finding is a localized change in the region of the splenic flexure of the colon, especially along its lateral margin (Fig. 8-100a). This is secondary to extension of the hemorrhage into the phrenicocolic ligament132 at this level (Fig. 8-l00b).

A specific structural lesion can be identified ultimately in most instances of bleeding into the anterior pararenal space. I have only rarely encountered a case of spontaneous, nontraumatic hemorrhage in which neither a vascular source nor a bleeding dyscrasia could be diagnosed (Fig. 8-101).

An unusual instance demonstrating urine leakage into the anterior pararenal space from a traumatic tear of the ureter after its exit from the cone of renal fascia is shown in Figure 8-102.

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