Working Diagnosis:
Gastric varices with splenic vein occlusion and perinephric hematoma collection

Treatment:
After consultation with Urology and IR, he was admitted for further management. He received a transfusion of pRBC. While awaiting admission to the floor, the patient had a large volume dark-bloody emesis and required 2U pRBC, 2U FFP, 1U platelets. GI was consulted emergently and IV PPI and octreotide were initiated. He was admitted to MICU for close monitoring.

Outcome:
He was monitored in the ICU and permitted a clear liquid diet. He remained on octreotide IV for 72 hours. He was started on a non-selective beta blocker (propranolol or nadolol) started with goal HR 50-60. CT angiogram was performed to evaluate patency of splenic vein given splenomegaly, and to evaluate for feasibility of Balloon-occluded retrograde transvenous obliteration (BRTO). IR was consulted and an ultrasound guided drainage was performed of left kidney subcapsular collection, yielding 100 mL of old hematoma fluid. Case Photo #5 Case Photo #6

IR performed a direct portogram via transhepatic access, which demonstrated occlusion of the central portion of the splenic vein with filling of gastric varices and gastrocolic trunk. Two overlapping bare-metal self-expanding stents were placed across the occlusion. Portogram subsequently showed brisk hepatopetal flow through the stented portion of the splenic vein and minimal contrast filling of gastric varices. Case Photo #7 Case Photo #8

He was subsequently discharged to home with recommendation for follow up EGD 4 weeks later. He was readmitted for recurrent perirenal hematoma Case Photo #9 Case Photo #10 , requiring IR placement of a drainage catheter. He ultimately retired from MMA.

Author's Comments:
Sports make up 10 percent of all traumatic abdominal injuries. Traumatic abdominal injuries are more common in the pediatric population and approximately 16-30 percent of pediatric traumatic renal injuries are from sports. Incidence is most common in contact and high velocity sports (cycling, skiing, etc.) Renal trauma accounts for 5% of blunt abdominal traumatic injuries and 86 percent of renal traumas occur with concomitant abdominal injuries. However, in sports renal trauma as an isolated injury is more common.

Presenting signs may include flank hematoma, abdominal or flank tenderness, rib fractures or hematuria defined as greater than 50 RBC noted on UA. Initial workup should include thorough laboratory assessment with UA, CBC, BMP, lipase, liver function tests, coagulation studies. A Contrast-enhanced CT is considered the gold standard for diagnosis.

Nonoperative management is appropriate for hemodynamically stable patients with renal trauma and the majority of injuries nonoperative management is adequate. Serial exams and ICU monitoring is critical. Angiography with embolization may be indicated in select patients and is preferred over operative management. Operative management is reserved in hemodynamically unstable, unresponsive to resuscitation measures, or failed nonoperative management.

Regarding return to play, athletes should not return to sport until hematuria has resolved, which can vary from 2-6 weeks.

Editor's Comments:
This case highlights the necessity of taking a thorough history in the athlete including past and present substance use. While athletes are generally healthy individuals, it is paramount to identify risk factors for more serious underlying conditions. While the vast majority of abdominal traumas can be managed nonoperatively, they can lead to potentially life-threatening injuries and should be carefully evaluated and monitored.

References:
Bernard JJ. Renal trauma: Evaluation, management, and return to play. Curr Sports Med Rep. 2009;8(2):98-103. doi:10.1249/JSR.0b013e31819e2e52
Brophy RH, Gamradt SC, Barnes RP, et al. Kidney injuries in professional American football: Implications for management of an athlete with 1 functioning kidney. Am J Sports Med. 2008;36(1):85-90. doi:10.1177/0363546507308940
Coccolini F, Moore EE, Kluger Y, et al. Kidney and uro-trauma: WSES-AAST guidelines. World J Emerg Surg. 2019;14(1):1-25. doi:10.1186/s13017-019-0274-x
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Patel DP, Redshaw JD, Breyer BN, et al. High-grade renal injuries are often isolated in sports-related trauma. Injury. 2015;46(7):1245-1249. doi:10.1016/j.injury.2015.02.008.
Singh S, Sookraj K. Kidney Trauma. [Updated 2020 Aug 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532896/?report=classic
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