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Splenic Injury

by Darren Malinoski, MD

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.

Etiology

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 ).

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

The main immediate consequence 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

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.

Pearls & Pitfalls

  • Ask patients with unexplained left upper quadrant abdominal pain about recent trauma (including contact sports), particularly if there is hypovolemia or shock.

Diagnosis

  • Imaging (CT or ultrasonography)

The diagnosis is confirmed with CT in stable patients and with bedside (point of care) ultrasonography or exploratory laparotomy in unstable patients.

Treatment

  • Observation

  • Sometimes surgical repair

In the past, treatment for any splenic injury was splenectomy. However, splenectomy should be avoided if possible, particularly in children, the elderly, 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 sp. and Haemophilus sp. may also be involved.

Currently, most low-grade and many high-grade splenic injuries can be managed nonoperatively, even in older patients (ie, > 55 yr). 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 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.

Patients who remain stable are transferred from the ICU after 12 to 48 h of observation, depending on the severity of their other injuries, and are discharged after becoming mobile and tolerating diet. The exact length of stay largely depends on grade of injury. Patients are advised to avoid strenuous exertion and contact sports for 2 to 3 mo.

Patients with significant ongoing hemorrhage (ie, significant ongoing transfusion requirements and/or declining Hct) require laparotomy. Sometimes when patients are hemodynamically stable, angiography with selective embolization of bleeding vessels is done.

When surgery is needed, hemorrhage can sometimes be controlled by suturing, topical hemostatic agents (eg, oxidized cellulose, thrombin compounds, fibrin glue), or partial splenectomy, but splenectomy is still sometimes necessary. Splenectomized patients should receive the pneumococcal vaccine; many clinicians also vaccinate against Neisseria and Haemophilus sp.

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.

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