Splenic rupture: Difference between revisions
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*Road traffic accidents | *Road traffic accidents | ||
*Contact sports injuries (Hockey and Football) | *Contact sports injuries (Hockey and Football) | ||
*Stab | *Stab wounds | ||
*Gunshot wounds | |||
*Domestic violence | *Domestic violence | ||
*Fist fights | *Fist fights | ||
Revision as of 13:29, 21 December 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
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 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: [1]
| 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:[1]
| WSES Class | Mechanism of injury | AAST | Hemodynamix Status | 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 | NOM + serial clinical/laboratory/radiological evaluation
Consider angiography/angioembolization |
NOM + serial clinical/laboratory/radiological evaluation |
| Moderate | WSES II | Blunt/penetrating | III | Stable | Consider angiography/angioembolization | ||
| WSES III | Blunt/penetrating | IV - V | Stable | NOM 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 | |||||||
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: 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. [2] [3]
- 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)[4]
| Causes of Splenic Rupture | |
|---|---|
| Traumatic causes | Non-Traumatic causes |
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Risk Factors
- Major risk factors for Splenic rupture include blunt or penetrating wounds as a result of contact sports and road accidents; colonoscopy procedures and infectious mononucleosis.
Screening
Natural History, Complications, and Prognosis
Diagnosis
Diagnostic Criteria
- In cases of ruptured spleen, a diagnostic peritoneal lavage helps in determining blood in the abdominal cavity. It is considered to be quick and inexpensive.
History and Symptoms
History
Symptoms
Symptoms of Splenic rupture include: [1] [7] [8] [9] [10]
- 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
Physical Examination
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
X-ray
Echocardiography or Ultrasound
- Focused abdominal sonographic technique (FAST)
CT scan
- A contrast CT of the abdomen may be hepful in determining an "active bleed" in cases of ruptured spleen. A CT scan is not recommended in patients with unstable vital signs. [11][12]
MRI
- Abdominal MRI is considered in patients with kidney failure allergic to the contrast dye used in CT scan.
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
References
- ↑ 1.0 1.1 1.2 Coccolini F, Montori G, Catena F, Kluger Y, Biffl W, Moore EE; et al. (2017). "Splenic trauma: WSES classification and guidelines for adult and pediatric patients". World J Emerg Surg. 12: 40. doi:10.1186/s13017-017-0151-4. PMC 5562999. PMID 28828034.
- ↑ Hildebrand DR, Ben-Sassi A, Ross NP, Macvicar R, Frizelle FA, Watson AJ (2014). "Modern management of splenic trauma". BMJ. 348: g1864. doi:10.1136/bmj.g1864. PMID 24696170.
- ↑ Aubrey-Bassler FK, Sowers N (2012). "613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review". BMC Emerg Med. 12: 11. doi:10.1186/1471-227X-12-11. PMC 3532171. PMID 22889306.
- ↑ Jehangir A, Poudel DR, Masand-Rai A, Donato A (2016). "A systematic review of splenic injuries during colonoscopies: Evolving trends in presentation and management". Int J Surg. 33 Pt A: 55–9. doi:10.1016/j.ijsu.2016.07.067. PMID 27479605.
- ↑ Invalid
<ref>tag; no text was provided for refs namedpmid21887533 - ↑ Invalid
<ref>tag; no text was provided for refs namedpmid19009661 - ↑ Barone JE, Burns G, Svehlak SA, Tucker JB, Bell T, Korwin S; et al. (1999). "Management of blunt splenic trauma in patients older than 55 years. Southern Connecticut Regional Trauma Quality Assurance Committee". J Trauma. 46 (1): 87–90. PMID 9932688.
- ↑ Beuran M, Gheju I, Venter MD, Marian RC, Smarandache R (2012). "Non-operative management of splenic trauma". J Med Life. 5 (1): 47–58. PMC 3307080. PMID 22574087.
- ↑ Pachter HL, Guth AA, Hofstetter SR, Spencer FC (1998). "Changing patterns in the management of splenic trauma: the impact of nonoperative management". Ann Surg. 227 (5): 708–17, discussion 717-9. PMC 1191351. PMID 9605662.
- ↑ Cadeddu M, Garnett A, Al-Anezi K, Farrokhyar F (2006). "Management of spleen injuries in the adult trauma population: a ten-year experience". Can J Surg. 49 (6): 386–90. PMC 3207549. PMID 17234065.
- ↑ Nwomeh BC, Nadler EP, Meza MP, Bron K, Gaines BA, Ford HR (2004). "Contrast extravasation predicts the need for operative intervention in children with blunt splenic trauma". J Trauma. 56 (3): 537–41. PMID 15128124.
- ↑ Willmann JK, Roos JE, Platz A, Pfammatter T, Hilfiker PR, Marincek B; et al. (2002). "Multidetector CT: detection of active hemorrhage in patients with blunt abdominal trauma". AJR Am J Roentgenol. 179 (2): 437–44. doi:10.2214/ajr.179.2.1790437. PMID 12130447.
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