Splenic rupture

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

The spleen is located in the upper left part of the abdomen (left-upper quadrant, left rib cage, or left flank) which helps in filtering the blood and removes old and damaged blood cells and platelets. The spleen also helps the immune system in the destruction of bacteria and removal of foreign substances. In adults, the spleen weighs 250 gms in weight and measures 13 cm in length. It has been observed that the spleen involutes with the increasing age and it isn't easily palpable in the adults when compared to children. As the spleen is a high vascular organ, it makes it susceptible to bleeding from the arteries, veins or parenchyma in an event of injury to it. The spleen is a highly vascularized organ, and an injury to this organ can result in significant blood loss either from the parenchyma or the arteries and veins that supply the spleen. Spleen also serves as an important lymphopoietic organ. Normal functioning of the spleen plays a major role in the opsonization of encapsulated organisms. Functions of the spleen include, hematologic functions such as the red cell maturation, phagocytosis, removal of particulates such as opsonized bacteria, or antibody-coated cells from blood and immunologic function which contributes to the humoral and cell-mediated immunity.

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	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	NOM + serial clinical/laboratory/radiological evaluation Consider angiography/angioembolization	NOM + serial clinical/laboratory/radiological evaluation
Moderate	WSES II	Blunt/penetrating	III	Stable			Consider angiography/angioembolization
	WSES III	Blunt/penetrating	IV - V	Stable		NOM 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

Pathophysiology

• The spleen is located in the upper left part of the abdomen (left-upper quadrant, left rib cage, or left flank) which helps in filtering the blood and removes old and damaged blood cells and platelets. The spleen also helps the immune system in the destruction of bacteria and removal of foreign substances. In adults, the spleen weighs 250 gms in weight and measures 13 cm in length. It has been observed that the spleen involutes with the increasing age and it isn't easily palpable in the adults when compared to children.
• As the spleen is a high vascular organ, it makes it susceptible to bleeding from the arteries, veins or parenchyma in an event of injury to it.
• The spleen is a highly vascularized organ, and an injury to this organ can result in significant blood loss either from the parenchyma or the arteries and veins that supply the spleen. Spleen also serves as an important lymphopoietic organ. Normal functioning of the spleen plays a major role in the opsonization of encapsulated organisms.
• Functions of the spleen include:
  • Hematologic function: Red cell maturation, phagocytosis (Extraction of abnormal cells), remove particulates such as opsonized bacteria, or antibody-coated cells from blood
  • Immunologic function: Contributes to the humoral and cell-mediated immunity

Causes

• The spleen is injured in an event of trauma to the lower left chest or the upper left abdomen.
• The nature of traumatic injury may be :
  • Penetrating traumatic injury (ex: abdominal gunshot wounds)
  • Blunt traumatic injury (ex: direct impact/blow to the left upper quadrant)
  • Indirect traumatic injury (ex: during colonoscopy procedure, splenic capsule tear may occur or it may result in traction on the splenocolic ligament)

Causes of Splenic Rupture
Traumatic causes	Non-Traumatic causes
Road traffic accidents Contact sports injuries (Hockey and Football) Stab wounds Gunshot wounds Domestic violence Fist fights	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.

Risk Factors

• Major risk factors for Splenic rupture include blunt or penetrating wounds as a result of contact sports and road accidents; colonoscopy procedures and infectious mononucleosis.

Diagnosis

Diagnostic Criteria

• In cases of ruptured spleen, a diagnostic peritoneal lavage (DPL) helps in determining blood in the peritoneal cavity. It is considered to be quick and inexpensive.
• Focused abdominal sonographic technique (FAST): FAST is a quick and safe procedure preferable in trauma patients to detect the presence of fluid in the peritoneal cavity.
• FAST is currently preferred over diagnostic peritoneal lavage (DPL) as it is non-invasive

History and Symptoms

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

Physical Examination

• Abdomen (left-upper quadrant, left rib cage and left flank) is palpated to determine size of the spleen for abdominal tenderness.
• Evaluation for external signs of trauma such as abrasions, lacerations, contusions, and seatbelt sign.
• Patients with splenic injury may present with hypovolemic shock resulting in tachycardia and hypotension.
• Signs suggestive of probable splenic injury:
  • Upper left quadrant tenderness
  • Peritonitis
  • Kehr's sign - Referred pain to the left shoulder
  • Left lower rib fracture (below the 6th rib - in approximately one-fifth of patients)

Laboratory Findings

• In an individual with stable vital signs and not in need of an emergency surgical intervention, a complete blood count (CBC) and hemoglobin (Hb) levels are measured in regular intervals in order to determine the amount of blood loss.

Electrocardiogram

• There are no specific ECG findings associated with Splenic rupture. However an ECG may be helpful in assessing the blood loss associated with Splenic rupture. ECG findings are suggestive of sinus tachycardia.

Echocardiography or Ultrasound

• Focused abdominal sonographic technique (FAST): FAST is a quick and safe procedure preferable in trauma patients to detect the presence of fluid in the peritoneal cavity. Focused abdominal sonographic technique consists of examining four acoustic windows such as the pericardiac, perihepatic, perisplenic and pelvic regions during assessment.

CT scan

• A contrast CT of the abdomen may be hepful in determining an "active bleed" in cases of ruptured spleen. A CT scan is not recommended in patients with unstable vital signs.

MRI

• Abdominal MRI is considered in patients with kidney failure allergic to the contrast dye used in CT scan.