A 16 year old male was thrown against the handlebars during a motorcycle crash at about 40 mph. He dusted himself off and went home for a few hours. Unfortunately, he slowly developed some abdominal pain.

He presented to an ED several hours later. He was found to have mild, diffuse abdominal pain, normal vital signs, and a positive abdominal FAST exam. CT scan showed a grade IV spleen injury and a grade II liver injury in the right lobe with no extravasation or pseudoaneurysm noted. He was successfully treated nonoperatively and was sent home.

One month later he returns to the ED complaining of a single episode of hematochezia (approximately 200cc). He has an entirely normal exam and vital signs.

Here are my questions for you:

• Was the initial management appropriate?
• Should anything additional have been done during the first admission?
• What is the diagnosis now?
• What diagnostic or therapeutic maneuvers are indicated now?

Please tweet your guesses, or leave comments below. Hints tomorrow and answers on Friday. Good luck!

Patient not treated at Regions Hospital