Splenic rupture

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.

Traumatic splenic rupture ^[1]

• Blunt abdominal trauma
  • Most frequently caused by motor vehicle accidents
  • Other settings of injury include contact sports, physical altercations, and falls from great heights
• Left-sided thoracic trauma with fractures of the lower ribs
• Penetrating abdominal trauma (e.g., stab wounds, gunshot wounds)
• Explosion-related blunt and/or penetrating trauma

Atraumatic splenic rupture ^[2]

• Severe splenomegaly due to, e.g.:
  • Infection (e.g., malaria, mononucleosis, HIV)
  • Leukemia (See “Clinical features” in “Acute leukemia” and “Chronic myeloid leukemia” for details.)
  • Inflammation (e.g., pancreatitis)
  • Medication related (e.g., anticoagulation)
  • Accumulation (e.g., amyloid protein in amyloidosis or glycogen in glycogen storage disorders)
  • Pregnancy ^[3]
  • Congestion secondary to portal hypertension
• Iatrogenic (post-surgery or post-endoscopy)

• 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 hematoma → asymptomatic interval (days to weeks) as hematoma distends inside the capsule → subsequent capsular rupture with intra-abdominal bleeding

• Diffuse abdominal pain, especially in the left upper quadrant (LUQ), possible abdominal guarding
  • Kehr's sign: referred pain in the left shoulder
  • Ballance's sign: dullness on percussion in the LUQ
• 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 blunt abdominal trauma for details)

• 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
      • Morison 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)

• Other injuries related to blunt abdominal trauma
  • Liver injury (e.g., hematoma, rupture)
  • Pancreatic injury (e.g., laceration, rupture)
  • Duodenal damage and hematoma, especially in children

References:^[4][5]

The differential diagnoses listed here are not exhaustive.

• 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
      • Alternative: partial splenic resection
    • 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!

Complications of splenic rupture

• Life-threatening hypovolemic and hemorrhagic shock
• Pancreatic injury (tail)

Complications of splenectomy

• Overwhelming post-splenectomy infection (OPSI): higher incidence of infection (see “Infection in asplenic patients” for details)
• Subphrenic abscess: an accumulation of pus located directly under the diaphragm ^[6]
  • Epidemiology
    • Reported in ∼ 2% of patients post abdominal surgery
    • No history of surgery in approx. 10% of patients
  • Etiology: polymicrobial infection (e.g., due to Enterococcus spp., E. coli, and Clostridium spp.) following intraperitoneal perforation
    • Most commonly a complication of surgery (e.g., splenectomy, gastrectomy) or secondary to conditions such as diverticulitis, duodenal ulcers, and appendicitis
    • Trauma
  • Pathophysiology: See “Abscess” for details.
  • Clinical features: most commonly develop 3–6 weeks after surgery
    • Fever
    • Pain over the 8^th–11^th ribs on the affected side
    • Cough, increased respiratory rate, pleural effusion
  • Diagnostics ^[7]
    • CBC: leukocytosis
    • Ultrasound can be used to visualize the abscess.
    • Chest x-ray shows air below the diaphragm.
  • Treatment: abscess drainage and antibiotic treatment (empiric, followed by tailored treatment according to antibiogram)
  • Complications: empyema, sepsis
  • Prognosis: high mortality (∼ 30%)

Overwhelming post-splenectomy infection is a potentially life-threatening complication.

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