Splenic rupture

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

Overview

Rupture of the capsule of the spleen, an organ in the upper left part of the abdomen, is a potential catastrophe that requires immediate medical and surgical attention.

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

• WSES Spleen Trauma Classification for adult and pediatric patients:

	WSES Class	Mechanism of injury	AAST	Hemodynamix 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.

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 gms in weight and measures 13 cm in length. It has been observed that the spleen involutes with the increasing age and it isn't easily palpable in the adults when compared to children.
• As the spleen is a high vascular organ, it makes it susceptible to bleeding from the arteries, veins or parenchyma in an event of injury to it.
• The spleen is a highly vascularized organ, and an injury to this organ can result in significant blood loss either from the parenchyma or the arteries and veins that supply the spleen. 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 function
  • Immunologic function
• Hematologic function:
  • Red cell maturation
  • Phagocytosis (Extraction of abnormal cells)
  • Remove particulates such as 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 (ex: abdominal gunshot wounds)
  • Blunt traumatic injury (ex: direct impact/blow to the left upper quadrant)
  • Indirect traumatic injury (ex: during colonoscopy procedure, splenic capsule tear may occur or it may result in traction on the splenocolic ligament)

Traumatic causes:

• Road traffic accidents
• Contact sports injuries (Hockey and Football)
• Stab and gunshot wounds
• Domestic violence
• Fist fights

Non-Traumatic causes:

• 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.

Diagnostic procedures

• Diagnostic procedures:

Diagnostic procedures
Adults	Pediatrics
The choice of diagnostic technique at admission must be based on the hemodynamic status of the patient (GoR 1A).	The role of E-FAST in the diagnosis of pediatric spleen injury is still unclear (GoR 1A).
E-FAST is effective and rapid to detect free fluid (GoR 1A).	A positive E-FAST examination in children should be followed by an urgent CT in stable patients (GoR 1B).
CT scan with intravenous contrast is the gold standard in hemodynamically stable or stabilized trauma patients (GoR 1A).	Complete abdominal US may avoid the use of CT in stable patients (GoR 1B).
Doppler US and contrast-enhanced US are useful to evaluate splenic vascularization and in follow-up (GoR 1B)	Contrast-enhanced CT scan is the gold standard in pediatric splenic trauma (GoR 1A).
Injury grade on CT scan, extent of free fluid, and the presence of PSA do not predict NOM failure or the need of OM (GoR 1B)	Doppler US and contrast-enhanced US are useful to evaluate splenic vascularization (GoR 1B).
	CT scan is suggested in children at risk for head and thoracic injuries, need for surgery, recurrent bleeding, and if other abdominal injuries are suspected (GoR 1A).
	Injury grade on CT scan, free fluid amount, contrast blush, and the presence of pseudo-aneurysm do not predict NOM failure or the need for OM (GoR 1B).

History and Symptoms

Symptoms

Symptoms of Splenic rupture include:

• Upper left 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

Electrocardiogram

X-ray

Echocardiography or Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

• Non-operative management:

Non-operative management
	Adults	Pediatrics
General indications		NOM is recommended as first-line treatment for hemodynamically stable pediatric patients with blunt splenic trauma (GoR 2A).
		Patients with moderate-severe blunt and all penetrating splenic injuries should be considered for transfer to dedicated pediatric trauma centers after hemodynamic stabilization (GoR2A).
		NOM of spleen injuries in children should be considered only in an environment that provides capability for patient continuous monitoring, angiography, and trained surgeons, an immediately available OR and immediate access to blood and blood products or alternatively in the presence of a rapid centralization system in those patients amenable to be transferred (GoR 2A).
		NOM should be attempted even in the setting of concomitant head trauma; unless the patient is unstable, this might be due to intra-abdominal bleeding (GoR 2B).
Blunt/penetrating trauma	Patients with hemodynamic stability and absence of other abdominal organ injuries requiring surgery should undergo an initial attempt of NOM irrespective of injury grade (GoR 2A).	Blunt trauma Blunt splenic injuries with hemodynamic stability and absence of other internal injuries requiring surgery, should undergo an initial attempt of NOM irrespective of injury grade (GoR 2A).
	NOM of moderate or severe spleen injuries should be considered only in an environment that provides capability for patient intensive monitoring, AG/AE, an immediately available OR and immediate access to blood and blood product or alternatively in the presence of a rapid centralization system and only in patients with stable or stabilized hemodynamic and absence of other internal injuries requiring surgery (GoR 2A).	In hemodynamically stable children with isolated splenic injury splenectomy should be avoided (GoR 1A).
	NOM in splenic injuries is contraindicated in the setting of unresponsive hemodynamic instability or other indicates for laparotomy (peritonitis, hollow organ injuries, bowel evisceration, impalement) (GoR 1A).	NOM is contraindicated in presence of peritonitis, bowel evisceration, impalement or other indications to laparotomy (GoR 2A).
	In patients being considered for NOM, CT scan with intravenous contrast should be performed to define the anatomic spleen injury and identify associated injuries (GoR 2A).	The presence of contrast blush at CT scan is not an absolute indication for splenectomy or AG/AE in children (GoR 2B).
	AG/AE may be considered the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan irrespective from injury grade (GoR 2B).	Intensive care unit admission in isolated splenic injury may be required only for moderate and severe lesions (GoR 2B).
	Strong evidence exists that age above 55 years old, high ISS, and moderate to severe splenic injuries are prognostic factors for NOM failure. These patients require more intensive monitoring and higher index of suspicion (GoR 2B).
	Age above 55 years old alone, large hemoperitoneum alone, hypotension before resuscitation, GCS < 12 and low-hematocrit level at the admission, associated abdominal injuries, blush at CT scan, anticoagulation drugs, HIV disease, drug addiction, cirrhosis, and need for blood transfusions should be taken into account, but they are not absolute contraindications for NOM (GoR 2B).
	In WSES class II–III spleen injuries with associated severe traumatic brain injury, NOM could be considered only if rescue therapy (OR and/or AG/AE) is rapidly available; otherwise, splenectomy should be performed (GoR 1C).
		Penetrating trauma No sufficient data validating NOM for penetrating spleen injury in children exist.
The role of angiography/angioembolization (AG/AE)	AG/AE may be performed in hemodynamically stable and rapid responder patients with moderate and severe lesions and in those with vascular injuries at CT scan (contrast blush, pseudo-aneurysms and arterio-venous fistula) (GoR 2A).	The vast majority of pediatric patients do not require AG/AE for CT blush or moderate to severe injuries (GoR 1C).
	In patients with bleeding vascular injuries and in those with intraperitoneal blush, AG/AE should be performed as part of NOM only in centers where AG/AE is rapidly available. In other centers and in case of rapid hemodynamic deterioration, OM should be considered (GoR 2B).	AG/AE may be considered in patients undergone to NOM, hemodynamically stable with sings of persistent hemorrhage not amenable of NOM, regardless with the presence of CT blush once excluded extra-splenic source of bleeding (GoR 1C).
	In case of absence of blush during angiography, if blush was previously seen at CT scan, proximal angioembolization could be considered (GoR 2C).	AG/AE may be considered for the treatment of post-traumatic splenic pseudo-aneurysms prior to patient discharge (GoR 2C).
	AG/AE should be considered in all hemodynamically stable patients with WSES grade III lesions, regardless with the presence of CT blush (GoR 1B).	Patients with more than 15 years old should be managed according to adults AG/AE-protocols (GoR 1C).
	AG/AE could be considered in patients undergone to NOM, hemodynamically stable with sings of persistent hemorrhage regardless with the presence of CT blush once excluded extra-splenic source of bleeding (GoR 1C).
	Hemodynamically stable patients with WSES grade II lesions without blush should not underwent routine AG/AE but may be considered for prophylactic proximal embolization in presence of risk factors for NOM failure (GoR 2B).
	In the presence of a single vascular abnormality (contrast blush, pseudo-aneurysms, and artero-venous fistula) in minor and moderate injuries, the currently available literature is inconclusive regarding whether proximal or distal embolization should be used. In the presence of multiple splenic vascular abnormalities or in the presence of a severe lesion, proximal or combined AG/AE should be used, after confirming the presence of a permissive pancreatic vascular anatomy (GoR 1C).
	In performing, AG/AE coils should be preferred to temporary agents (GoR 1C).

Surgery

• Operative management:

Operative management (OM)
Adults	Pediatrics
OM should be performed in patients with hemodynamic instability and/or with associated lesions like peritonitis or bowel evisceration or impalement requiring surgical exploration (GoR 2A).	Patients should undergo to OM in case of hemodynamic instability, failure of conservative treatments, severe coexisting injuries necessitating intervention and peritonitis, bowel evisceration, impalement (GoR 2A).
OM should be performed in moderate and severe lesions even in stable patients in centers where intensive monitoring cannot be performed and/or when AG/AE is not rapidly available (GoR 2A).	Splenic preservation (at least partial) should be attempted whenever possible (GoR 2B).
Splenectomy should be performed when NOM with AG/AE failed, and patient remains hemodynamically unstable or shows a significant drop in hematocrit levels or continuous transfusion are required (GoR 2A).
During OM, salvage of at least a part of the spleen is debated and could not be suggested (GoR 2B).
Laparoscopic splenectomy in early trauma scenario in bleeding patients could not be recommended (GoR 2A).

Follow-up

Short- and long-term follow-up:

Short- and long-term follow-up
Adults	Pediatrics
Clinical and laboratory observation associated to bed rest in moderate and severe lesions is the cornerstone in the first 48–72 h follow-up (GoR 1C).	In hemodynamic stable children without drop in hemoglobin levels for 24 h, bed rest should be suggested (GoR 2B).
CT scan repetition during the admission should be considered in patients with moderate and severe lesions or in decreasing hematocrit, in presence of vascular anomalies or underlying splenic pathology or coagulopathy, and in neurologically impaired patients (GoR 2A).	The risk of pseudo-aneurysm after splenic trauma is low, and in most of cases, it resolves spontaneously (GoR 2B).
In the presence of underlying splenic pathology or coagulopathy and in neurologically impaired patients CT follow-up is to be considered after the discharge (GoR 2B).	Angioembolization should be taken into consideration when a pesudoaneurysm is found (GoR 2B).
Activity restriction may be suggested for 4–6 weeks in minor injuries and up to 2–4 months in moderate and severe injuries (GoR 2C).	US (DUS, CEUS) follow-up seems reasonable to minimize the risk of life-threatening hemorrhage and associated complications in children (GoR 1B).
	After NOM in moderate and severe injuries, the reprise of normal activity could be considered safe after at least 6 weeks (GoR 2B).