Diagnosis: Traumatic Splenic Injury with Peritoneal Irritation
This 25-year-old male post-MVA with LLQ pain, guarding, and a positive Rovsing's sign (radiating left-sided pain when pressing on RLQ) most likely has splenic injury with peritoneal irritation, and requires immediate CT abdomen/pelvis with IV contrast followed by surgical consultation.
Immediate Diagnostic Approach
Obtain CT abdomen and pelvis with IV contrast emergently - this is the imaging examination of choice for evaluating acute abdominal pain in trauma patients, with 98% overall accuracy and ability to demonstrate solid organ injuries, free fluid, and other causes of abdominal pain 1.
Key Clinical Findings Suggesting Splenic Injury
- LLQ pain with guarding indicates peritoneal irritation from blood or fluid in the left upper quadrant tracking to the LLQ 1
- Positive Rovsing's sign (pain radiating to the left when pressing on the right) suggests peritoneal irritation with blood irritating the peritoneum diffusely 2
- Post-MVA mechanism - blunt abdominal trauma from MVA commonly causes splenic injury, with mean ISS of 35 ± 12 in MVA patients requiring urgent intervention 3
Why CT with IV Contrast is Critical
- IV contrast improves detection of bowel wall abnormalities, solid organ injuries (spleen, liver, kidney), vascular pathology, and intraabdominal fluid collections 1
- Stratifies for operative versus nonoperative management based on severity of injury and presence of active extravasation 1
- Identifies alternative diagnoses including bowel perforation, mesenteric injury, or other trauma-related pathology 1
Differential Diagnosis in Post-Trauma LLQ Pain
While splenic injury is most likely, CT will also evaluate for:
- Colonic injury - particularly descending colon or splenic flexure 1
- Renal injury - left kidney trauma can present with LLQ pain 1
- Diaphragmatic rupture - can cause referred LLQ pain 1
- Traumatic diverticulitis (unlikely in 25-year-old but possible) - would show intestinal wall thickening and pericolonic inflammation 1
Management Algorithm Based on CT Findings
If CT Shows Splenic Injury:
- Hemodynamically stable with low-grade injury (Grade I-III): Nonoperative management with serial hemoglobin checks, strict bed rest, and ICU monitoring 1
- Hemodynamically unstable or high-grade injury (Grade IV-V): Immediate surgical consultation for splenectomy or splenorrhaphy 1, 3
- Active contrast extravasation: Consider angioembolization if hemodynamically stable, or surgery if unstable 1
If CT Shows Bowel Perforation:
- Free air or bowel wall discontinuity: Emergent surgical exploration 1
- Mortality rates are higher with larger amounts of extraluminal air 1
If CT Shows Isolated Peritoneal Fluid Without Solid Organ Injury:
- Consider mesenteric injury or occult bowel injury: Serial abdominal exams and repeat imaging in 6-12 hours if clinical deterioration 1
Critical Pitfalls to Avoid
- Do not delay CT imaging for prolonged clinical observation in post-trauma patients with peritoneal signs - CT changes management in the majority of acute abdominal pain cases 1, 4
- Do not obtain plain radiographs first - they are extremely limited in evaluating trauma and significantly less sensitive than CT for detecting free air, solid organ injury, or intraabdominal fluid 1
- Do not use ultrasound as the sole initial study in blunt abdominal trauma with peritoneal signs - while FAST exam may detect free fluid, it cannot characterize solid organ injuries or determine need for operative intervention 1
- Do not assume diverticulitis in a 25-year-old - this is extremely rare in this age group, and post-trauma mechanism makes traumatic injury far more likely 1
Hemodynamic Monitoring
- Obtain baseline hemoglobin, type and cross for potential transfusion 3
- Monitor vital signs continuously - tachycardia and hypotension indicate ongoing hemorrhage requiring immediate surgical intervention 3
- Hospital mortality is 30% in MVA patients requiring urgent laparotomy for massive hemoperitoneum 3