Splenic Rupture After Extracorporeal Shock Wave Lithotripsy

A 60-year-old woman presented with recurrent left renal colic. Excretory urography confirmed a 20 x 11 mm. calculus in the left renal pelvis (fig. l). On the day of treatment she was well. With the patient under general anesthesia ureteral stent insertion and ESWL were performed without incident. The calculus was easily localized under fluoroscopic guidance and it fragmented well after 3,000 shocks at 24 kV. using the Dornier MFL 5000. Postoperatively signs were normal but the patient complained of pain and required analgesia. Seven hours after ESWL she was pale, sweaty, in pain, tachycardic (heart rate 100 beats per minute) and hypotensive (blood pressure 100/60 mm. Hg). On physical examination the abdomen was not distended, and there were bowel sounds and tenderness in the left loin with no rebound. Voiding demonstrated slight hematuria. Appropriate resuscitative measures were performed. Hemoglobin was 10.3 gm./dl. (13.8 before ESWL, normal 11.5 to 16.5). Blood was cross-matched and 2 units of packed cells were given. The working diagnosis was renal hematoma and conservative management was planned based on clinical parameters. No imaging studies were done at that time. Three hours later the condition seemed improved with better fluid and pain management. Abdominal findings were unchanged but the patient complained of left shoulder tip pain (which was not brought to the attention of the