Splenic rupture

Intra-parenchymal blush observed on helical CT scan

Mechanism

1) Blunt trauma (common)

2) Penetrating

3) Combination of blunt and penetrating (often seen in explosive effect)

Pathophysiology

-More common in pre existing spleen problem (Infectious mononucleosis etc)

-acute or chronic enlargement of the spleen often accompanied with thinning of splenic capsule, hence making it more fragile.

Clinical presentation (staging from I-V on CT Scan)

Minor focal injury

-right upper quadrant abdominal tenderness.

-Left shoulder tenderness due to sub diaphragmatic nerve root irritation with referred pain (Kehr Signs)

With Intra abdominal injury

- Signs of shock (>5-10% blood loss)

- abdominal distension, peritoneal signs, and overt shock (progress with the blood loss)

** Hypotension in suspected splenic rupture patient esp. who is previously healthy young man require urgent attention.

Useful procedure

-Focused abdominal sonographic technique (FAST)

- CT Scan

-MRI

Grade 4-5 splenic laceration on helical CT scan

Management

1) Conservative management in stable patient recognized by this signs

- Stable hemodynamic signs

- Stable hemoglobin levels over 12-48 hours

- Minimal transfusion requirements (2 U or less)

- CT scan injury scale grade of 1 or 2 without a blush

- Patients younger than 55 years

2) Splenic angioembolization

- Splenic artery and branches embolization with gel foam or metal coil via femoral artery

- Not perform in most hospital as it require great synchronization between trauma specialist and radiologist.

3) Surgical therapy

- In ongoing bleed patient or hemodynamic instability

- Emergency celiotomy for hemoperitoneum with suspected splenic injury (midline abdominal incision approach rather than intercostals to explore possible intra abdominal bleeding.

Complication

1) Of non operative care

- Delayed bleeding

- Splenic cyst formation

- Splenic necrosis

2) Of splenectomy

- Bleeding

- Infection by encapsulated organism, mostly pneumococcus

3) Of Angioembolism

- Noninfectious-related febrile events

- sympathetic pleural effusions

- Left upper quadrant abscesses

- Femoral arteriovenous fistulas and iliofemoral pseudoaneurysms

- Gel foam used in angioembolism may mistakenly identify as abcess

4) Other complication

- Posttraumatic splenic pseudocysts

- Thrombocytosis links with vascular problem

- Adjacent organ necrosis or abcess

Reference:

Author: H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc

Coauthor(s): Janet S Bjerke, BSN, RN, MBA, CCRC, Research Coordinator, Trauma Services, Methodist Hospital, Indianapolis