Rupture of the Spleen

Splenic rupture is a medical emergency that carries a significant risk of hypovolemic shock and death. Injury to the spleen accounts for nearly half of all injuries to intra-abdominal organs. The most common reason for a rupture of the spleen is blunt abdominal trauma, specifically, motor vehicle accidents. For individuals with splenomegaly, however, even minimal trauma may result in splenic injury or rupture. Patients often present with LUQ abdominal pain; however, pain may be referred to the left shoulder. Patients are at risk for hemodynamic instability due to blood loss. The diagnosis is generally made with CT imaging, and management, ranging from observation to splenectomy, depends on the patient’s hemodynamic stability.

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Overview

Definition

Splenic rupture is often associated with trauma (e.g., motor vehicle accident) that causes a laceration of the organ.

Epidemiology

  • The spleen is the most commonly injured and ruptured organ in the abdomen:
    • 50%–75% of cases caused by blunt trauma (most common cause) 
    • Rate of injury after blunt abdominal trauma may be as high as 7.5%.
  • More common in males
  • Peak incidence in young adults (ages 18–34)

Etiology

  • Trauma:
    • Motor vehicle accident (most common cause)
    • Direct abdominal blow
    • Fall
  • Nontraumatic:
    • Malignancy
    • Infection
    • Iatrogenic (e.g., surgical manipulation of the organ)

Pathophysiology

Splenic rupture can have serious consequences because of the unique physiologic function of the spleen.

  • Highly vascular secondary lymphatic organ central to the immune system 
  • Functions to filter blood and remove old or damaged erythrocytes
  • Located posterolaterally in the LUQ beneath the left hemidiaphragm lateral to the greater curvature of the stomach
  • Splenomegaly: enlargement of the spleen
    • Numerous causes:
      • Hepatic portal vein of outflow congestion
      • Splenic infiltration
      • Infection 
    • Leads to ↑ risk of splenic rupture
Anatomy of the spleen all views

Location of the spleen

Image by BioDigital, edited by Lecturio

Clinical Presentation

History

  • Trauma to the LUQ
  • Splenomegaly 
  • History of condition associated with splenomegaly: 
    • Sickle cell disease
    • Malaria
    • Lymphoma
    • EBV

Physical examination

  • Vital signs:
    • Tachycardia and hypotension: Signs of shock may occur with large-volume blood loss.
  • Abdominal exam:
    • Visible laceration or sign of blunt trauma to the abdomen
    • Seatbelt sign may be seen in patients who present after a motor vehicle accident.
    • Palpable splenomegaly
    • Abdominal tenderness, guarding, rigidity
    • Pain referred to the left shoulder (Kehr’s sign)

Diagnosis

Physical examination and history may be useful, but not all patients with splenic rupture present with clinically significant findings.

Imaging

  • FAST: 
    • Most useful in hemodynamically unstable trauma patients
    • Positive FAST examination = hypoechoic (black) rim around spleen
    • Negative FAST exam does not rule out splenic rupture.
  • CT scan:
    • Preferred in hemodynamically stable patients with IV (+/– oral) contrast
    • 98% sensitive for splenic injuries when IV contrast is given
    • Will show splenic hypodensities, extravasation of IV contrast
    • CT is excellent for grading the severity of injury and determining whether a patient will require surgery.
CT of abdomen Rupture of Spleen

CT of abdomen of patient with splenic rupture:
Splenic rupture has multiple possible etiologies. Clinical exam and history are often insufficient for diagnosis. A CT of the abdomen can reveal areas of hematoma (H) or free blood.
S: spleen

Image: “Spleen with large subcapsular hematoma” by de Kubber MM et al. License: CC BY 2.0

Management

Management of splenic rupture depends on the patient’s hemodynamic status:

  • Hemodynamically stable:
    • Observation for 10–14 days
    • Nonoperative management 
    • Blood transfusion and pain control as needed
    • Patients advised to avoid strenuous activity for 6–8 weeks 
    • Consider angiographic embolization.
  • Hemodynamically unstable:
    • Emergent exploratory laparotomy
    • Splenectomy is considered for patients with ongoing blood loss requiring transfusion of ≥ 4 units of blood.
Splenic artery embolization Rupture of Spleen

Splenic artery embolization:
This image shows angiographic embolization in the setting of splenic injury. Great improvements have been made in outcomes with nonsurgical treatment of hemodynamically stable patients.

Image: “Splenic angiography obtained after the selective embolization” by Popovic P et al. License: CC BY 3.0

Splenectomy

  • Resection of injured portions of the spleen
  • Severe hematologic and immunologic consequences
  • Goal of surgery is to preserve spleen and perform partial resection (particularly important in children).
  • Complications:
    • Severe hemorrhage and hypovolemic shock
    • Immunosuppression: increased risk of sepsis from polysaccharide bacterial infection
    • Complication involving the pancreas: injury or infection

Postsplenectomy:

Asplenic patients require vaccination against encapsulated bacteria:

  • Haemophilus influenzae
  • Streptococcus pneumoniae
  • Neisseria meningitidis

Clinical Relevance

  • Spleen: solid organ shaped like a coffee bean and weighing about 150 g. The spleen is located in the left posterior upper abdomen (epigastric region) and is positioned adjacent to ribs 9 through 11. The spleen has red and white pulp, which act to filter blood cells and activate the immune system, respectively. This organ is composed of very soft tissue, and as such, is at high risk for laceration and injury after abdominal trauma.
  • Abdominal trauma and penetrating abdominal injury: classified according to the mechanism of injury as blunt or penetrating. Blunt abdominal trauma is the most common type of abdominal trauma that presents to the ED. Individuals who have been in a motor vehicle accident can present with a classic physical examination finding called the seatbelt sign. Different structures can be injured, including the duodenum, spleen, liver, kidneys, and pelvic organs. Computed tomography is the imaging of choice for patients who are hemodynamically stable.
  • Asplenia: absence of a spleen. The most common anatomical reason for asplenia is surgical removal. Only rarely is asplenia congenital, and if this is the case, it is often associated with a malformation of the big thoracic vessels. Asplenia is termed “functional” when the organ is still present in the patient but does not work owing to repeated microscopic injury. Sickle cell disease is a commonly tested cause of functional asplenia. Patients should be appropriately vaccinated to prevent sepsis from infections caused by encapsulated bacteria.
  • Mononucleosis: infectious mononucleosis, also known as “the kissing disease.” Mononucleosis is a highly contagious disease caused by EBV. The common name for mononucleosis comes from its frequent method of transmission through saliva. A well-known complication of mononucleosis is splenomegaly, which predisposes patients to splenic rupture.
  • Splenomegaly: a massive enlargement of the spleen. Splenomegaly makes the spleen palpable under the left costal arch. Ultrasound shows a bulging shape and rounding of the normally pointed ends of the spleen. Any ectopic tissue, such as accessory spleens, would also be hypertrophied. Splenomegaly may be caused by venous outflow blockage, splenic infarction, malignancy, and ongoing infection. The 1st line of management is treatment of the underlying cause. Splenectomy is considered for patients with considerable symptoms not alleviated by treatment of the underlying disorder.

References

  1. Akoury, T., Whetstone, D. R. (2020) Splenic rupture. StatPearls. Retrieved Xxxxx XX, 2021, from Xxxxx.
  2. Coccolini, F., Montori, G., et al. (2017). Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World Journal of Emergency Surgery 12(40).
  3. Lieberman, M. E., Levitt, M. A. (1989). Spontaneous rupture of the spleen: a case report and literature review. Am J Emerg Med 7:28-31.
  4. Maung, A. A., Kaplan, L. J. (2019). Management of splenic injury in the adult trauma patient. UpToDate. Retrieved April 22, 2021, from https://www.uptodate.com/contents/management-of-splenic-injury-in-the-adult-trauma-patient

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