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.

Causes

Common Causes

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.

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 an organ in the upper left side of the abdomen that filters the blood by removing old or damaged blood cells and platelets and helps the immune system by destroying bacteria and other foreign substances. It also holds extra blood that can be released into the circulatory system, if needed.

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

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).

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.

Prognosis

Splenic rupture permits large amounts of blood to leak into the abdominal cavity which is severely painful and life-threatening. Shock and, ultimately, death can result. Patients typically require an urgent operation, although it is becoming more common to simply monitor the patient to make sure the bleeding stops by itself and to allow the spleen to heal itself. Rupture of a normal spleen can be caused by trauma, for example, in an accident. If an individual's spleen is enlarged, as is frequent in mononucleosis, most physicians will not allow activities (such as major contact sports) where injury to the abdomen could be catastrophic.

Prevention

The spleen is a useful but nonessential organ. It is sometimes removed (otherwise known as a splenectomy) in people who have blood disorders, such as thalassemia or hemolytic anemia. If the spleen is removed, a person must get certain immunizations to help prevent infections that the spleen normally fights.

Related Chapters

• Infectious mononucleosis
• Splenomegaly
• Kehr's sign

Resources

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