• Clinical science

Splenic rupture

Abstract

Injury to the spleen is most often the result of blunt abdominal trauma. In rare cases, it may also be caused by spontaneous rupture from an infection or a hematological condition. A ruptured spleen may result in massive intra-abdominal bleeding and should therefore be treated as a medical emergency. Rupture of the spleen may be acute or delayed: acute rupture, in which the patient immediately presents in severe pain and shock, is differentiated from a delayed rupture, which presents with sudden onset of pain and shock following a symptom-free interval lasting days to weeks. Depending on the severity of the injury, conservative therapy with observation in a high dependency unit may be considered, but most patients require surgical intervention. A splenic salvage maneuver (i.e., suturing, coagulation) is performed when possible; however, a splenectomy is commonly indicated in extensive injury involving the splenic hilum and may be a life-saving procedure.

Etiology

References:[1]

Classification

Classification of splenic injury

Grade I (minor injury, e.g., subcapsular tear) to Grade V (major injury including shattered spleen/hilar laceration), according to the type of laceration and the location of the hematoma.

Grade Injury Management
Grade I Subcapsular hematoma/capsular laceration Conservative/monitoring
Grade II Superficial parenchymal/capsular laceration Surgical intervention: if possible, a splenic salvage maneuver
Grade III Deep parenchymal laceration Surgical intervention: if possible, a splenic salvage maneuver
Grade IV Fragmented spleen with major devascularization Surgical intervention: splenectomy, a partial splenic resection if possible
Grade V Hilar laceration/shattered spleen

Surgical intervention: splenectomy

References:[2]

Pathophysiology

  • Anatomy
    • The spleen lies within the intraperitoneal cavity and is protected by the rib cage.
    • Close proximity to: stomach (intraperitoneal), colon (transverse: intraperitoneal, descending: retroperitoneal), left kidney, pancreas (both retroperitoneal)
    • Highly vascularized organ
    • Lymphatic organ with filtering function
  • Mechanisms of splenic rupture
    • Acute rupture: injury of the splenic capsule and possibly the splenic parenchymal tissue → acute intra-abdominal bleeding
    • Delayed rupture: injury of the splenic parenchymal tissue in an initially intact splenic capsule → central or subcapsular hematomaasymptomatic interval (days to weeks) as hematoma distends inside the capsule → subsequent capsular rupture with intra-abdominal bleeding

References:[3]

Clinical features

  • Diffuse abdominal pain, especially in the left upper quadrant (LUQ), possible abdominal guarding
  • Hemorrhagic shock (often delayed): tachycardia and hypotension
  • In delayed splenic rupture, symptoms may not present until days to weeks after trauma

It is important to identify signs of any other major life-threatening injury in a polytrauma patient! (see differential diagnoses below)References:[3]

Diagnostics

  • Laboratory tests: low Hb, leukocytosis, and thrombocytosis ; crossmatch for blood transfusion if needed
  • In hemodynamically unstable patients
    • First ultrasound: focused assessment with sonography (FAST):
      • Screening for central or subcapsular hematoma
      • Free intra-abdominal fluid – preferred sites of collection:
        • Koller pouch: splenorenal recess
        • Morrison's pouch: hepatorenal recess
        • Pouch of Douglas: between the rectum and, the bladder (in males) or uterus (in the females)
    • If free intraabdominal fluid → diagnostic laparoscopy/laparotomy

Repeated ultrasound examination is crucial, especially in conservative management of splenic rupture!

  • In hemodynamically stable patients (or in unstable patients in which temporary stabilization with IV fluid resuscitation is successful)
    • Method of choice: abdominal CT scan (with contrast)
    • Alternative: MRI , angiography
    • Sometimes: chest x-ray, abdominal x-ray
  • Always consider other organs that could be injured (see “Differential diagnosis” below)

References:[3]

Differential diagnoses

  • Other injuries related to abdominal trauma
    • Liver injury (e.g., hematoma, rupture)
    • Pancreatic laceration: deep abdominal pain , poor appetite, fever/chills
      • Mangement: percutaneous drainage (with culture) and debridement to prevent complications such as pseudocysts or abscess
    • Blunt abdominal trauma can cause also cause duodenal damage and hematoma, especially in children
      • Management
        • Nasogastric suction and parenteral nutrition to allow healing
        • If patients remain unstable, laparotomy may be indicated

References:[4][5]

The differential diagnoses listed here are not exhaustive.

Treatment

  • If low-grade injury in hemodynamically stable patients
    • Conservative management; (e.g. hospital observation with frequent ultrasound examination)
    • Angiographic embolization of the injured blood vessel is becoming more widely-used in stable patients
  • If high-grade splenic injuries and/or hemodynamically unstable patients
    • Laparotomy
      • If only peripheral rupture: trial of splenic salvage – suturing, coagulation, or ligation of the injured blood vessel
      • If hilar rupture: splenectomy
        • If necessary, reimplantation of splenic tissue
    • Alternative: consider angiographic embolization if patients are stable

Splenectomy is a life-saving procedure in cases of high-grade spleen rupture or continuous bleeding!References:[3][2][6]

Complications

  • Life-threatening hypovolemic and hemorrhagic shock
  • Post-splenectomy: higher incidence of infection, overwhelming post-splenectomy infection (OPSI; see asplenism)
  • Pancreatic injury (tail)

Overwhelming post-splenectomy infection is a potenitally life-threatening complication!

References:[3][6]

We list the most important complications. The selection is not exhaustive.