• Clinical science

Splenic rupture

Summary

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]

Pathophysiology

  • Anatomy
  • 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:[2]

Clinical features

It is important to identify signs of any other major life-threatening injury in a polytrauma patient! (see differential diagnoses below)References:[2]

Diagnostics

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:[2]

Differential diagnoses

References:[3][4]

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
        • 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!References:[2][5][6]

Complications

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

References:[2][6]

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