Splenic rupture

WikiDoc Resources for Splenic rupture
Articles
Most recent articles on Splenic rupture Most cited articles on Splenic rupture Review articles on Splenic rupture Articles on Splenic rupture in N Eng J Med, Lancet, BMJ
Media
Powerpoint slides on Splenic rupture Images of Splenic rupture Photos of Splenic rupture Podcasts & MP3s on Splenic rupture Videos on Splenic rupture
Evidence Based Medicine
Cochrane Collaboration on Splenic rupture Bandolier on Splenic rupture TRIP on Splenic rupture
Clinical Trials
Ongoing Trials on Splenic rupture at Clinical Trials.gov Trial results on Splenic rupture Clinical Trials on Splenic rupture at Google
Guidelines / Policies / Govt
US National Guidelines Clearinghouse on Splenic rupture NICE Guidance on Splenic rupture NHS PRODIGY Guidance FDA on Splenic rupture CDC on Splenic rupture
Books
Books on Splenic rupture
News
Splenic rupture in the news Be alerted to news on Splenic rupture News trends on Splenic rupture
Commentary
Blogs on Splenic rupture
Definitions
Definitions of Splenic rupture
Patient Resources / Community
Patient resources on Splenic rupture Discussion groups on Splenic rupture Patient Handouts on Splenic rupture Directions to Hospitals Treating Splenic rupture Risk calculators and risk factors for Splenic rupture
Healthcare Provider Resources
Symptoms of Splenic rupture Causes & Risk Factors for Splenic rupture Diagnostic studies for Splenic rupture Treatment of Splenic rupture
Continuing Medical Education (CME)
CME Programs on Splenic rupture
International
Splenic rupture en Espanol Splenic rupture en Francais
Business
Splenic rupture in the Marketplace Patents on Splenic rupture
Experimental / Informatics
List of terms related to Splenic rupture

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

Common Causes

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.

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; OM - Operative management; NOM - Non-Operative management (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.

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:

• 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

Diagnostic procedures

Diagnostic procedures
Adults	Pediatrics
The choice of diagnostic technique at admission must be based on the hemodynamic status of the patient (GoR 1A).	The role of E-FAST in the diagnosis of pediatric spleen injury is still unclear (GoR 1A).
E-FAST is effective and rapid to detect free fluid (GoR 1A).	A positive E-FAST examination in children should be followed by an urgent CT in stable patients (GoR 1B).
CT scan with intravenous contrast is the gold standard in hemodynamically stable or stabilized trauma patients (GoR 1A).	Complete abdominal US may avoid the use of CT in stable patients (GoR 1B).
Doppler US and contrast-enhanced US are useful to evaluate splenic vascularization and in follow-up (GoR 1B)	Contrast-enhanced CT scan is the gold standard in pediatric splenic trauma (GoR 1A).
Injury grade on CT scan, extent of free fluid, and the presence of PSA do not predict NOM failure or the need of OM (GoR 1B)	Doppler US and contrast-enhanced US are useful to evaluate splenic vascularization (GoR 1B).
	CT scan is suggested in children at risk for head and thoracic injuries, need for surgery, recurrent bleeding, and if other abdominal injuries are suspected (GoR 1A).
	Injury grade on CT scan, free fluid amount, contrast blush, and the presence of pseudo-aneurysm do not predict NOM failure or the need for OM (GoR 1B).

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

• Infectious mononucleosis
• Splenomegaly
• Kehr's sign

Resources

• Template:MerckHome
• Template:MerckManual