(See also Overview of Abdominal Trauma Overview of Abdominal Trauma The abdomen can be injured in many types of trauma; injury may be confined to the abdomen or be accompanied by severe, multisystem trauma. The nature and severity of abdominal injuries vary... read more .)
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 Infectious Mononucleosis Infectious mononucleosis is caused by Epstein-Barr virus (EBV, human herpesvirus type 4) and is characterized by fatigue, fever, pharyngitis, and lymphadenopathy. Fatigue may persist weeks or... read more 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.
Splenic injuries are classified according to severity into 5 grades.
Grades of Splenic Injury
Subcapsular hematoma < 10% of surface area
Laceration < 1 cm deep
Subcapsular hematoma 10‒50% of surface area, intraparenchymal hematoma < 5 cm
Laceration 1‒3 cm deep and not involving a trabecular vessel
Subcapsular hematoma > 50% of surface area, intraparenchymal hematoma ≥ 5 cm, any expanding or ruptured hematoma
Laceration > 3 cm deep or involving a trabecular vessel
Laceration involving segmental or hilar vessels and that devascularizes > 25% of spleen
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 Shock Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death. Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes... read more . 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
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 Femoral Shaft Fractures Femoral shaft fractures usually result from severe force and are clinically obvious. Treatment is with immediate splinting with traction followed by open reduction with internal fixation (ORIF)... read more ). 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 Treatment reference 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... read more ).
Similar to hepatic injuries Hepatic Injury Hepatic injury can result from blunt or penetrating trauma. Patients have abdominal pain, sometimes radiating to the shoulder, and tenderness. Diagnosis is made by CT or ultrasonography. Treatment... read more , 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.
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 species.
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
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.
Drugs Mentioned In This Article
|Drug Name||Select Trade|
|Recothrom, Thrombi-Gel , Thrombin-JMI, Thrombin-JMI Epistaxis, Thrombi-Pad, Thrombogen|
|Pneumovax 23, Pnu-Imune-23 , Prevnar, Prevnar 13 , Prevnar 20, VAXNEUVANCE|