Basics
Description
- The spleen is formed by reticular and lymphatic tissue and is the largest lymph organ.
- The spleen lies posterolaterally in the left upper quadrant (LUQ) between the fundus of the stomach and the diaphragm.
Etiology
- The spleen is the most commonly injured intra-abdominal organ:
- In nearly 2/3 of cases, it is the only damaged intraperitoneal structure
- Blunt mechanisms are more common
- Motor vehicle accidents (auto " “auto, pedestrian " “auto) are the major cause (50 " “75%), followed by blows to the abdomen (15%) and falls (6 " “9%)
- Mechanism of injury and kinematics are important factors in evaluating patients for possible splenic injury.
- Splenic injuries are graded by type and severity of injury [American Association for the Surgery of Trauma (AAST) criteria]:
- Grade I:
- Hematoma: Subcapsular, <10% surface area
- Laceration: Capsular tear, <1 cm in parenchymal depth
- Grade II:
- Hematoma: Subcapsular, 10 " “50% surface area; intraparenchymal, <5 cm in diameter
- Laceration: Capsular tear, 1 " “3 cm in parenchymal depth and not involving a trabecular vessel
- Grade III:
- Hematoma: Subcapsular, >50% surface area or expanding, ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma, ≥5 cm or expanding
- Laceration: >3 cm in parenchymal depth or involving the trabecular vessels
- Grade IV:
- Laceration: Involving the segmental or hilar vessels and producing major devascularization (>25% of spleen)
- Grade V:
- Laceration: Completely shattered spleen
- Vascular: Hilar vascular injury that devascularizes the spleen
- Poorly developed musculature and relatively smaller anteroposterior diameter increase the vulnerability of abdominal contents to compressive forces.
- Rib cage is extremely compliant and less prone to fracture in children but provides only partial protection against splenic injury.
- Splenic capsule in children is relatively thicker than that of an adult; parenchyma of spleen seems to contain more smooth muscle than in adults.
- Significant abdominal injury occurs in only about 5% of child abuse cases but is the 2nd most common cause of death after head injury.
Diagnosis
Signs and Symptoms
History
- In blunt trauma, note the type and direction (horizontal or vertical) of any deceleration or compressive forces:
- Injuries are caused by compression of the spleen between the anterior abdominal wall and the posterior thoracic cage or vertebra (e.g., lap-belt restraints).
- In penetrating trauma, note the characteristic of the weapon (type and caliber), distance from the weapon, or the type and length of knife or impaling object:
- Injuries result from a combination of the kinetic energy and shear forces of penetration.
Physical Exam
- Systemic signs from acute blood loss:
- Syncope, dizziness, weakness, confusion
- Hypotension or shock
- Local signs:
- LUQ abdominal tenderness
- Palpable tender mass in LUQ (Balance sign)
- Referred pain to the left shoulder (Kehr sign)
- Abdominal distention, rigidity, rebound tenderness, involuntary guarding
- Contusions, abrasions, or penetrating wounds to the chest, flank, or abdomen may indicate underlying spleen injury.
- Fractures of lower left ribs are commonly seen in association with splenic injuries.
Age-related difficulties in communication, fear-induced uncooperative behavior, or a concomitant head injury make clinical exam less reliable. ‚
Essential Workup
- History and physical exam are neither specific nor sensitive for splenic injury.
- Adjunctive imaging studies are required.
Diagnosis Tests & Interpretation
Lab
- No hematologic lab studies are specific for diagnosis of injury to the spleen.
- Obtain baseline hemoglobin, type and cross-match, and chemistries.
Imaging
- Plain abdominal radiographs:
- Too nonspecific to be of value
- CXR findings suggestive for splenic injury:
- Left lower rib fracture(s)
- Elevation of left hemidiaphragm
- Medial displacement of gastric bubble (Balance sign)
- Left pleural effusion
- Ultrasound:
- Routinely performed at bedside in trauma patients as part of focused assessment with sonography (FAST)
- Primary role is detecting free intraperitoneal blood, which may suggest splenic injury
- Does not image solid parenchymal damage well
- Technically compromised by uncooperative patient, obesity, substantial bowel gas, and subcutaneous air
- CT scan:
- Noncontrast CT is procedure of choice in stable patient due to speed and accessibility
- Depicts the presence and extent of splenic injury and adjacent organs, including the retroperitoneum
- Provides the most specific information in patients stable enough to go to the CT scanner
- MRI:
- May be applicable to subset of hemodynamically stable patients who cannot undergo CT scan (e.g., allergic to IV contrast)
- Angiography:
- Has been added to the diagnostic and treatment options for selected cases
Diagnostic Procedures/Surgery
- Diagnostic peritoneal lavage (DPL):
- Extremely sensitive for the presence of hemoperitoneum although nonspecific for source of bleeding and does not evaluate retroperitoneum
- Largely replaced by the FAST exam in most major trauma centers.
Differential Diagnosis
- Intraperitoneal organ injury, especially liver
- Injury to retroperitoneal structures
- Thoracic injury
Treatment
Pre-Hospital
- Obtain details of injury from pre-hospital providers.
- IV access
- Penetrating wounds or evisceration should be covered with sterile dressings.
Initial Stabilization/Therapy
- Airway management (including C-spine immobilization)
- Standard Advanced Trauma Life Support (ATLS) resuscitation measures:
- Adequate IV access, including central lines and cutdowns, as dictated by the patient 's hemodynamic status
- Fluid resuscitation, initially with 2 L of crystalloid (NS or lactated Ringer solution), followed by blood products as needed
Ed Treatment/Procedures
- Immediate laparotomy may be appropriate in the acutely injured and hemodynamically unstable patient with presumed hemoperitoneum and splenic injury.
- Most patients with acute splenic injury either are hemodynamically stable or stabilize rapidly with relatively small amounts of fluid resuscitation.
- Adjunctive diagnostic procedures supplementing the physical exam should be performed early in the evaluation, followed by laparotomy when indicated by positive diagnostic findings.
- Gunshot wounds to the anterior abdomen are routinely explored in the OR.
- Stab wounds can be managed by local wound exploration, followed by US or DPL when intraperitoneal penetration is suspected.
- Operative vs. nonoperative management:
- Patients with signs and symptoms of intraperitoneal hemorrhage, those with operative indications based on imaging//diagnostic procedures, and those who fail nonoperative management should undergo laparotomy.
- Angiographic embolization is an option in hemodynamically stable patient
- Splenectomy vs. splenic salvage depends on the grade of splenic injury.
- >70% of all stable patients are currently being treated via nonoperative management:
- Hemodynamic stability
- Negative abdominal exam
- Absence of contrast extravasation on CT
- Absence of other clear indications for exploratory laparotomy
- Absence of associated health conditions that carry an increased risk for bleeding (e.g., coagulopathy, hepatic failure, anticoagulant use, coagulation factor deficiency)
- Injury grades I " “III
- Patients >55 yr should be considered for operative management due to decreased physical tolerance to traumatic insult (splenic capsule thins with age) and reduced physiologic reserve.
- Embolization is relatively contraindicated in patients >55 yr due to higher failure rates in these patients.
- Nonoperative management of splenic injuries is considered safe:
- Concerns for overwhelming postsplenectomy infection/sepsis
Follow-Up
Disposition
Admission Criteria
All patients with splenic injury require hospitalization for definitive laparotomy or observation with serial abdominal exams, serial hematocrit determinations, and bed rest. ‚
Discharge Criteria
Only asymptomatic patients objectively demonstrated not to have splenic or other traumatic injury may be discharged. ‚
Additional Reading
- Bhullar ‚ IS, Frykberg ‚ ER, Siragusa ‚ D, et al. Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management. J Trauma Acute Care Surg. 2012;72:1127 " “1134.
- Gomez ‚ D, Haas ‚ B, Al-Ali ‚ K, et al. Controversies in the management of splenic trauma. Injury. 2012;43:55 " “61.
- Izu ‚ BS, Ryan ‚ M, Markert ‚ RJ, et al. Impact of splenic injury guidelines on hospital stay and charges in patients with isolated splenic injury. Surgery. 2009;146(4):787 " “791.
- St Peter ‚ SD, Keckler ‚ SJ, Spilde ‚ TL, et al. Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg. 2008;43:191 " “194.
- Tinkoff ‚ G, Esposito ‚ TJ, Reed ‚ J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: Spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008;207(5):646 " “655.
Codes
ICD9
- 865.00 Injury to spleen without mention of open wound into cavity, unspecified injury
- 865.01 Injury to spleen without mention of open wound into cavity, hematoma without rupture of capsule
- 865.02 Injury to spleen without mention of open wound into cavity, capsular tears, without major disruption of parenchyma
- 865.09 Other injury into spleen without mention of open wound into cavity
- 865.03 Injury to spleen without mention of open wound into cavity, laceration extending into parenchyma
- 865.04 Injury to spleen without mention of open wound into cavity, massive parenchymal disruption
- 865.0 Injury to spleen without mention of open wound into cavity
ICD10
- S36.00XA Unspecified injury of spleen, initial encounter
- S36.029A Unspecified contusion of spleen, initial encounter
- S36.039A Unspecified laceration of spleen, initial encounter
- S36.09XA Other injury of spleen, initial encounter
- S36.020A Minor contusion of spleen, initial encounter
- S36.021A Major contusion of spleen, initial encounter
- S36.030A Superficial (capsular) laceration of spleen, initial encounter
- S36.031A Moderate laceration of spleen, initial encounter
- S36.032A Major laceration of spleen, initial encounter
SNOMED
- 23589004 Injury of spleen (disorder)
- 262820001 Contusion of spleen (disorder)
- 262822009 Laceration of spleen (disorder)
- 210180009 Closed injury of spleen (disorder)
- 262823004 Capsular tear of spleen (disorder)
- 262824005 Transection of spleen (disorder)
- 43756009 Traumatic rupture of spleen (disorder)