An interesting cause of collapse in a patient with chronic pancreatitis

A 55-year-old man attended the emergency department following an episode of collapse. He was known to have chronic pancreatitis and a pancreatic pseudocyst. He had recently been recumbent due to chronic abdominal pain. On arrival he was unwell. Baseline observations revealed an oxygen saturation of 87% on room air, pulse 115 bpm and blood pressure 86/57 mm Hg. Physical examination was unremarkable except for mild abdominal tenderness. He was started on high-flow oxygen, intravenous fluid and broad-spectrum antibiotics. A chest x-ray was unremarkable. Massive pulmonary embolus was considered a likely diagnosis. The patient underwent an urgent CT pulmonary angiogram (CTPA). As this was undertaken as an urgent investigation straight from the resuscitation area a d-dimer test was not performed. The CTPA showed no evidence of pulmonary embolism but demonstrated a subdiaphragmatic collection. An arterial phase abdominal CT scan was thus performed, which confirmed a large subcapsular splenic haematoma and splenic vein thrombosis. The patient was resuscitated with blood products and transferred for splenic artery embolisation.