Akutni abdomen nakon embolizacije slezene uslijed imunosne trombocitopenije – prikaz bolesnika

Mark Žižak, Višnja Nesek Adam, Sanja Berić, Ranko Smiljanić

Bolesnica u dobi od 56 godina hospitalizirana je zbog trombocitopenije teškog stupnja koja se manifestirala epistaksom, krvarenjem iz desni i hematomima po koži. Više od deset godina liječi se od imune trombocitopenije (ITP) i do sada je uspješno reagirala na terapiju glukokortikoidima, intravenskim imunoglobulinima i hidroksiklorokinom. Odmah po prijmu na odjel hematologije započeto je liječenje imunosupresivnom i trombopoetskom terapijom. Budući da nije bilo odgovora, ponovno su uvedeni intravenski imunoglobulini (IVIG), nakon čega je došlo do prolaznog porasta broja trombocita na 57 x 109/L, no učinak je trajao samo tri dana. Budući da se radilo o trombocitopeniji refraktornoj na konzervativno liječenje, konzultiran je kirurg glede odstranjenja slezene. Zbog rizika od krvarenja tijekom zahvata, kirurg je preporučio embolizaciju slezene kao manje invazivnu metodu liječenja. Postupak embolizacije prošao je uredno, no kasnije dolazi do pogoršanja općeg stanja uslijed razvoja peritonitisa. Intraoperacijski je nađena nekroza i perforacija želudca te je učinjena splenektomija i resekcija nekrotičnog dijela želudca. Poslijeoperacijski tijek kompliciran je razvojem respiratornih komplikacija uz ponovni pad broja trombocita, što je zahtijevalo dodatne transfuzije trombocita i primjenu IVIG-a. Zbog ponovljenih bolova u trbuhu, kontinuirane drenažne sekrecije i razvoja pneumoperitoneuma indiciran je ponovno operacijski zahvat. S obzirom na to da i nakon revizijskog zahvata nije došlo do smanjenja sekrecije, kontrolnim MSCT-om verificirana je uska fistula želudca koja se zbrine gastroskopski okluzijom metalnom klipsom. Potom dolazi do smanjenja sekrecije na dren, bolesnici se postupno uvede enteralna prehrana koju uredno tolerira te se otpusti kući nakon ukupno 95 dana liječenja. Ovaj slučaj naglašava kompleksnost liječenja refraktorne ITP te važnost ranog prepoznavanja i liječenja postembolizacijskih komplikacija.

A 56-year-old female patient was hospitalized due to severe thrombocytopenia manifested by epistaxis, gum bleeding, and skin hematomas. She has been treated for immune thrombocytopenia (ITP) for over 10 years and has previously responded successfully to glucocorticoids, intravenous immunoglobulins, and hydroxychloroquine. Upon admission to the hematology department, treatment with immunosuppressive and thrombopoietic therapy was initiated. Since there was no response, intravenous immunoglobulins (IVIG) were reintroduced, resulting in a transient increase in platelet count to 57×109/L, but the effect lasted only three days. Considering
it was thrombocytopenia refractory to conservative treatment, a surgeon was consulted regarding splenectomy. Due to the risk of bleeding during the procedure, the surgeon recommended splenic embolization as a less invasive treatment method. The embolization procedure went smoothly, but later the patient’s general condition deteriorated due to the development of peritonitis. Intraoperatively, gastric necrosis and perforation were found, and splenectomy and resection of the necrotic part of the stomach were performed. The postoperative course was complicated by respiratory complications and a recurrent drop in platelet count, which required additional platelet transfusions and IVIG administration. Due to recurring abdominal pain, continuous drain output, and the development of pneumoperitoneum, another surgical intervention was indicated. Since abdominal drainage did not decrease after the revision procedure, a follow-up MSCT verified a narrow gastric fistula, which was managed gastroscopically by occlusion with a metal clip. Subsequently, the drainage decreased, the patient was gradually introduced to enteral nutrition which she tolerated well, and she was discharged home after a total of 95 days of teratreatment. This case highlights the complexity of treating refractory ITP and the importance of early recognition and management of post-embolization complications.