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
Life Threatening Causes
Common Causes
Common Causes: [1]
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. [2][3]
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
(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. | |||||||
Causes by Organ System
| Cardiovascular | No underlying causes |
| Chemical/Poisoning | No underlying causes |
| Dental | No underlying causes |
| Dermatologic | No underlying causes |
| Drug Side Effect | Filgastrim, Tbo-filgrastim |
| Ear Nose Throat | No underlying causes |
| Endocrine | No underlying causes |
| Environmental | No underlying causes |
| Gastroenterologic | No underlying causes |
| Genetic | No underlying causes |
| Hematologic | No underlying causes |
| Iatrogenic | No underlying causes |
| Infectious Disease | No underlying causes |
| Musculoskeletal/Orthopedic | No underlying causes |
| Neurologic | No underlying causes |
| Nutritional/Metabolic | No underlying causes |
| Obstetric/Gynecologic | No underlying causes |
| Oncologic | No underlying causes |
| Ophthalmologic | No underlying causes |
| Overdose/Toxicity | No underlying causes |
| Psychiatric | No underlying causes |
| Pulmonary | No underlying causes |
| Renal/Electrolyte | No underlying causes |
| Rheumatology/Immunology/Allergy | No underlying causes |
| Sexual | No underlying causes |
| Trauma | No underlying causes |
| Urologic | No underlying causes |
| Miscellaneous | No underlying causes |
Causes in Alphabetical Order
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: [4] [5] [6] [7] [8]
- 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
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
Resources
References
- ↑ 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.
- ↑ Fishback SJ, Pickhardt PJ, Bhalla S, Menias CO, Congdon RG, Macari M (2011). "Delayed presentation of splenic rupture following colonoscopy: clinical and CT findings". Emerg Radiol. 18 (6): 539–44. doi:10.1007/s10140-011-0982-3. PMID 21887533.
- ↑ Guerra JF, San Francisco I, Pimentel F, Ibanez L (2008). "Splenic rupture following colonoscopy". World J Gastroenterol. 14 (41): 6410–2. PMC 2766127. PMID 19009661.
- ↑ 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.
- ↑ 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.
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