Splenic rupture

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Reddy Kothagadi M.B.B.S[2]

Overview

The spleen is located in the upper left part of the abdomen (left-upper quadrant, left rib cage, or left flank). The spleen helps in filtering the blood and removes old and damaged blood cells and platelets. The spleen also helps the immune system in the destruction of bacteria and removal of foreign substances. In adults, the spleen is 250 grams in weight and measures 13 cm in length. It has been observed that the spleen involutes with the increasing age and it is less easily palpable in the adults when compared to children. The spleen, a highly vascular organ, is susceptible to bleeding from the arteries, veins or parenchyma in an event of injury to it. An injury to this organ can result in significant blood loss either from the parenchyma or the arteries and veins that supply the spleen. The spleen also serves as an important lymphopoietic organ. Normal functioning of the spleen plays a major role in the opsonization of encapsulated organisms. Functions of the spleen include hematologic functions such as the red cell maturation, phagocytosis, removal of particulates such as opsonized bacteria, or antibody-coated cells from blood and immunologic function which contributes to the humoral and cell-mediated immunity.

Classification

• American Association for the Surgery of Trauma (AAST) Spleen Trauma Classification:

American Association for the Surgery of Trauma (AAST) Spleen Trauma Classification
Grade	Injury description
I	Hematoma	Subcapsular, < 10% surface area
	Laceration	Capsular tear, < 1 cm parenchymal depth
II	Hematoma	Subcapsular, 10–50% surface area
		Intraparenchymal, < 5 cm diameter
	Laceration	1–3 cm parenchymal depth not involving a perenchymal vessel
III	Hematoma	Subcapsular, > 50% surface area or expanding
		Ruptured subcapsular or parenchymal hematoma
		Intraparenchymal hematoma > 5 cm
	Laceration	> 3 cm parenchymal depth or involving trabecular vessels
IV	Laceration	Laceration of segmental or hilar vessels producing major devascularization (> 25% of spleen)
V	Laceration	Completely shatters spleen
	Vascular	Hilar vascular injury which devascularized spleen

Pathophysiology

• The spleen is located in the upper left part of the abdomen (left-upper quadrant, left rib cage, or left flank) which helps in filtering the blood and removes old and damaged blood cells and platelets. The spleen also helps the immune system in the destruction of bacteria and removal of foreign substances. In adults, the spleen weighs 250 grams and measures 13cm in length. It has been observed that the spleen involutes with the increasing age and is less easily palpable in the adults when compared to children.
• The spleen is a highly vascular organ making it susceptible to bleeding from the arteries, veins or parenchyma in an event of injury to it.
• The spleen also serves as an important lymphopoietic organ. Normal functioning of the spleen plays a major role in the opsonization of encapsulated organisms.
• Hematologic functions of the spleen include:
  • Red cell maturation
  • phagocytosis (extraction of abnormal cells)
  • Opsonized bacteria, or antibody-coated cells from blood
• Immunologic function: Contributes to the humoral and cell-mediated immunity

Causes

• The spleen is injured in an event of trauma to the lower left chest or the upper left abdomen.
• The nature of traumatic injury may be :
  • Penetrating traumatic injury (e.g. abdominal gunshot wounds)
  • Blunt traumatic injury (e.g. direct impact/blow to the left upper quadrant)
  • Indirect traumatic injury (e.g. during colonoscopy, splenic capsule tear may occur or it may result in traction on the splenocolic ligament)

Causes of Splenic Rupture
Traumatic causes	Non-Traumatic causes
Road traffic accidents Contact sports injuries (Hockey and Football) Stab wounds Gunshot wounds Domestic violence Fist fights	Pancreatitis (Acute and Chronic) Lymphoma (malignant haematological disorders) Leukaemia (malignant haematological disorders) Splenic neoplasms such as the angiosarcoma and haemangioma Langerhans cell histiocytosis (non-malignant haematological disorders) Viral infections such as the infectious mononucleosis, HIV and cytomegalovirus (CMV) infection Bacterial infections such as the infectious endocarditis and tuberculosis Parasitic infections such as the malaria Primary and secondary amyloidosis Colonoscopy procedure increases the risk of splenic rupture.

Differentiating Splenic rupture from other conditions

• Splenic rupture must be differentiated from other conditions such as infectious mononucleosis, fractured ribs, traumatic injury to the left kidney or the intestines and injuries to the surrounding musculoskeletal structures.

Risk Factors

• Major risk factors for Splenic rupture include blunt or penetrating wounds as a result of contact sports and road accidents; colonoscopy procedures, hemolytic anemia, certain lymphomas and infectious mononucleosis.

Screening

• There is insufficient evidence to recommend routine screening for Splenic rupture.

Natural History, Complications, and Prognosis

Natural History

• If left untreated, patients with splenic rupture may progress to develop fatal and life-threatening complications such as gross internal bleeding which may lead to coma.

Complications

• Complications of splenic rupture include, internal bleeding, splenic abscess, sepsis progressing to peritonitis, pancreatitis, necrosis and thrombocytosis (late complication)

Prognosis

• Prognosis is usually good after after surgical management. Patients undergoing splenectomy are more susceptible to infections from encapsulated organisms.

Diagnosis

Diagnostic Criteria

• Focused abdominal sonographic technique (FAST): FAST is a quick and safe procedure preferable in trauma patients to detect the presence of fluid in the peritoneal cavity.
• FAST is currently preferred over diagnostic peritoneal lavage (DPL) as it is non-invasive
• A diagnostic peritoneal lavage (DPL) helps in determining blood in the peritoneal cavity. It is considered to be quick and inexpensive but is not preferred when FAST is available.

History and Symptoms

History

• History of trauma to the left rib cage, left upper quadrant or left flank. Absence of injuries in these regions doesn't rule out the possibility of splenic injury.
• A previous surgical history of procedures such as splenectomy and a history of liver or portal venous disease should be evaluated. Medical history of use of aspirin or NSAIDs (nonsteroidal anti inflammatory drugs), anticoagulants, bleeding tendency and anticoagulants.
• A possible splenic rupture patient may or may not show tenderness, rigidity, or distention on arrival.

Symptoms

Symptoms of Splenic rupture include:

• Left upper quadrant abdominal pain

• Upper left abdominal tenderness
• Left shoulder pain (Sharp pain - Kehr's sign)
• Confusion, dizziness and lightheadedness
• Blurred vision
• Tachycardia ("racing heart" feel)
• Profuse sweating
• Dyspnea
• Extensive injury may result in excessive bleeding leading to hypotension and finally hypovolemic shock

Physical Examination

• Abdomen (left-upper quadrant, left rib cage and left flank) is palpated to determine size of the spleen for abdominal tenderness.
• Evaluation for external signs of trauma such as abrasions, lacerations, contusions, and seatbelt sign.
• Patients with splenic injury may present with hypovolemic shock resulting in tachycardia and hypotension.
• Signs suggestive of probable splenic injury:
  • Left upper quadrant tenderness
  • Peritonitis
  • Kehr's sign - Referred pain to the left shoulder
  • Left lower rib fracture (below the 6th rib - in approximately one-fifth of patients)

Laboratory Findings

• In an individual with stable vital signs and not in need of an emergency surgical intervention, a complete blood count (CBC) and hemoglobin (Hb) levels are measured in regular intervals in order to determine the amount of blood loss.

Electrocardiogram

• There are no specific ECG findings associated with splenic rupture. However an ECG may be helpful in assessing the blood loss associated with splenic rupture. ECG findings are suggestive of sinus tachycardia.

X-ray

• X-ray is not the preferred imaging modality in a case of splenic rupture.

Echocardiography or Ultrasound

• Focused abdominal sonographic technique (FAST): FAST is a quick and safe procedure preferable in trauma patients to detect the presence of fluid in the peritoneal cavity. Focused abdominal sonographic technique consists of examining four acoustic windows such as the pericardiac, perihepatic, perisplenic and pelvic regions during assessment.

CT scan

• A contrast CT of the abdomen may be helpful in determining an "active bleed" in cases of ruptured spleen. A CT scan is not recommended in patients with unstable vital signs.

MRI

• Abdominal MRI is considered in patients with kidney failure allergic to the contrast dye used in CT scan.

Treatment

Medical Therapy

• WSES Spleen Trauma Classification for adult and pediatric patients:

	WSES Class	Mechanism of injury	AAST	Hemodynamic Status (a), (b)	CT scan	First-line treatment in adults	First-line treatment in pediatric
Minor	WSES I	Blunt/penetrating	I - II	Stable	Yes + local exploration in SW (d)	NOM (c) + serial clinical/laboratory/radiological evaluation Consider angiography/angioembolization	NOM (c) + serial clinical/laboratory/radiological evaluation
Moderate	WSES II	Blunt/penetrating	III	Stable			Consider angiography/angioembolization
	WSES III	Blunt/penetrating	IV - V	Stable		NOM (c) All angiography/angioembolization + serial clinical/laboratory/radiological evaluation
Severe	WSES IV	Blunt/penetrating	I - V	Unstable	No	OM	OM
SW - Stab wound; GSW - Gunshot wound; OM - Operative management; NOM - Non-Operative management (a) Hemodynamic instability in adults is considered the condition in which the patient has an admission systolic blood pressure < 90 mmHg with evidence of skin vasoconstriction (cool, clammy, decreased capillary refill), altered level of consciousness and/or shortness of breath, or > 90 mmHg but requiring bolus infusions/transfusions and/or vasopressor drugs and/or admission base excess (BE) > − 5 mmol/l and/or shock index > 1 and/or transfusion requirement of at least 4–6 units of packed red blood cells within the first 24 h; moreover, transient responder patients (those showing an initial response to adequate fluid resuscitation, and then signs of ongoing loss and perfusion deficits) and more in general those responding to therapy but not amenable of sufficient stabilization to be undergone to interventional radiology treatments. (b) Hemodynamic stability in pediatric patients is considered systolic blood pressure of 90 mmHg plus twice the child’s age in years (the lower limit is inferior to 70 mmHg plus twice the child’s age in years, or inferior to 50 mmHg in some studies). Stabilized or acceptable hemodynamic status is considered in children with a positive response to fluid resuscitation: 3 boluses of 20 mL/kg of crystalloid replacement should be administered before blood replacement; positive response can be indicated by the heart rate reduction, the sensorium clearing, the return of peripheral pulses and normal skin color, an increase in blood pressure and urinary output, and an increase in warmth of extremity. Clinical judgment is fundamental in evaluating children (c) NOM should only be attempted in centers capable of a precise diagnosis of the severity of spleen injuries and capable of intensive management (close clinical observation and hemodynamic monitoring in a high dependency/intensive care environment, including serial clinical examination and laboratory assay, with immediate access to diagnostics, interventional radiology, and surgery and immediately available access to blood and blood products or alternatively in the presence of a rapid centralization system in those patients amenable to be transferred (d) Wound exploration near the inferior costal margin should be avoided if not strictly necessary because of the high risk to damage the intercostal vessels.

Surgery

• Surgical intervention is recommended as the first-line treatment option for the management of splenic rupture in patients with blunt trauma or penetrating injuries and those who are hemodynamically unstable, and associated complications such as peritonitis, bowel evisceration and other complications which require emergent surgical intervention.
• Surgical intervention is also suggested for stable patients with moderate to severe lesions where intensive care and monitoring aren't avaialble and also where angiography and angioembolization aren't readily available.
• Splenectomy is recommended in cases where angiography and angioembolization procedures are unsuccessful and the patient is hemodynamically unstable (patients in whom the hematocrit levels are dropping and who require continuous transfusion). Salvage of a part of the spleen during surgical intervention isn't recommended remains debatable.
• Patients in early trauma and who are bleeding, laparoscopic splenectomy may not be recommended.

Primary Prevention

• Individuals with infectious mononucleosis are strictly recommended to refrain from contact sports or activities which may increase the risk for possibilities of splenic rupture until complete recovery.