Splenic injury usually results from blunt abdominal trauma. Patients often have abdominal pain, sometimes radiating to the shoulder, and tenderness. Diagnosis is made by CT or ultrasonography. Treatment is with observation and sometimes surgical repair; rarely, splenectomy is necessary.
(See also Overview of Abdominal Trauma.)
Etiology of Splenic Injury
Significant impact (eg, motor vehicle crash) can damage the spleen as can penetrating trauma (eg, knife wound, gunshot wound). Splenic enlargement as a result of fulminant Epstein-Barr viral disease (infectious mononucleosis or posttransplant Epstein-Barr virus–mediated pseudolymphoma) predisposes to rupture with minimal trauma or even spontaneously. Splenic injuries range from subcapsular hematomas and small capsular lacerations to deep parenchymal lacerations, crush injury, and avulsion from the pedicle.
Classification
Splenic injuries are classified according to severity into 5 grades.
Grades of Splenic Injury
Grade | Injury |
|---|---|
1 | Subcapsular hematoma < 10% of surface area Laceration < 1 cm deep |
2 | Subcapsular hematoma 10‒50% of surface area, intraparenchymal hematoma < 5 cm Laceration 1‒3 cm deep and not involving a trabecular vessel |
3 | Subcapsular hematoma > 50% of surface area, intraparenchymal hematoma ≥ 5 cm, any expanding or ruptured hematoma Laceration > 3 cm deep or involving a trabecular vessel |
4 | Laceration involving segmental or hilar vessels and that devascularizes > 25% of spleen |
5 | Completely shattered spleen Hilar vascular injury that devascularizes spleen |
Pathophysiology of Splenic Injury
The main immediate consequence of a splenic injury is hemorrhage into the peritoneal cavity. The amount of hemorrhage ranges from small to massive, depending on the nature and degree of injury. Many small lacerations, particularly in children, cease bleeding spontaneously. Larger injuries hemorrhage extensively, often causing hemorrhagic shock. A splenic hematoma sometimes ruptures, usually in the first few days, although rupture can occur from hours to even months after injury.
Symptoms and Signs of Splenic Injury
The manifestations of major hemorrhage, including hemorrhagic shock, abdominal pain, and distention, are usually clinically obvious. Lesser hemorrhage causes left upper quadrant abdominal pain, which sometimes radiates to the left shoulder. Patients with unexplained left upper quadrant pain, particularly if there is evidence of hypovolemia or shock, should be asked about recent trauma. Maintain a high index of suspicion for splenic injury in patients who have left rib fractures.
Pearls & Pitfalls
|
Diagnosis of Splenic Injury
Imaging (CT or ultrasonography)
A splenic injury is confirmed with CT in stable patients and with bedside (point of care) ultrasonography or exploratory laparotomy in unstable patients.
Treatment of Splenic Injury
Observation
Angioembolization
Sometimes surgical repair or splenectomy
In the past, treatment for any splenic injury was splenectomy. However, splenectomy should be avoided if possible, particularly in older patients, children, and patients with hematologic malignancy, to avoid the resulting permanent susceptibility to bacterial infections, increasing the risk of overwhelming postsplenectomy sepsis. The most common pathogen is Streptococcus pneumoniae, but other encapsulated bacteria such as Neisseria and Haemophilus species may also be involved.
Currently, most low-grade and many high-grade splenic injuries can be managed nonoperatively, even in patients > 55 years. Hemodynamically stable patients who have no other indications for laparotomy (eg, hollow viscus perforation) can be observed with monitoring of vital signs and serial abdominal examinations and hematocrit (Hct) levels. Need for transfusion is compatible with nonoperative management, particularly when there are other associated injuries (eg, long-bone fractures). However, there should be a predetermined transfusion threshold (typically 2 units for isolated splenic injuries) beyond which surgery should be done to prevent morbidity and mortality. In one high-volume trauma center, of those who fail nonoperative management, 75% fail within 2 days, 88% within 5 days, and 93% within 7 days of injury (1).
Similar to hepatic injuries, there is no consensus in the literature regarding duration of restricted activity, optimum length of stay in the intensive care unit (ICU) or hospital, timing of resumption of diet, or need for repeat imaging for splenic injuries managed nonoperatively. However, the more severe the injury, the more care should be taken before permitting resumption of activities that may involve heavy lifting, contact sports, or torso trauma.
Patients with significant ongoing hemorrhage (ie, significant ongoing transfusion requirements and/or declining hematocrit [Hct]) require laparotomy. Sometimes when patients are hemodynamically stable, angiography with selective embolization of bleeding vessels is done.
Neisseria and Haemophilus species.
Treatment reference
Stassen NA, Bhullar I, Cheng JD: Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 73:S288-S293, 2012. doi: 10.1097/TA.0b013e318270160d
Key Points
Splenic injury is common and can occur with minimal trauma if the spleen is enlarged.
The main complications are immediate bleeding and delayed hematoma rupture.
Confirm the diagnosis with CT in stable patients and with exploratory laparotomy in unstable patients.
To avoid permanently increasing the patient's susceptibility to bacterial infections (caused by splenectomy), manage splenic injuries nonoperatively when possible.
Do laparotomy or angiography with embolization in patients who have significant ongoing transfusion requirements and/or declining Hct.
