Continuing Education Activity

Injuries to the spleen are one of the most common injuries in abdominal trauma. The spleen is the most vascular organ in the body. Since bleeding in splenic injuries is mainly arterial, significant haemoperitoneum can occur. Unrecognized injury can be a cause of preventable traumatic death. This activity reviews the framework for the evaluation and initial management of patients with abdominal trauma with a suspected injury of the spleen and highlights the role of the interprofessional team in managing the patients presenting with it.

Objectives:

• Describe the typical imaging findings to aid in the diagnosis of suspected splenic injury.
• Explain the common physical exam findings associated with splenic injury in patients with abdominal trauma.
• Review the conservative management of trauma patients with suspected spleen injuries.
• Employ interprofessional team strategies for improving care coordination and communication to advance and improve outcomes for the trauma patients with suspected spleen injuries.

Introduction

Injuries to the spleen are one of the most common injuries in abdominal trauma. Unrecognized injury can be a cause of preventable traumatic death. [1][2] 

The spleen is the most vascular organ in the body. Since bleeding in splenic injuries is mainly arterial, significant hemoperitoneum can occur. Also, bleeding from injuries to the spleen is mainly intraperitoneal.

Because of the immunological functions of the spleen, there is a trend toward salvaging the spleen rather than removing it in traumatic cases. The development of CT scans has made conservative management of splenic injuries possible today.

Etiology

The spleen is susceptible to injury if the trauma involves the lower left chest or the upper left abdomen.[3][4] It is vulnerable to injury during trauma because of its juxtaposition in the left upper abdomen to the 9th, 10th, and 11th ribs

The following are three mechanisms of injury:

• Penetrating trauma, for example, abdominal gunshot wounds occur in 7% to 9% of total penetrating trauma cases
• Blunt trauma, for example, a direct blow to the left upper quadrant
• Indirect trauma, for example, a tear in the splenic capsule during colonoscopy or traction on the splenocolic ligament

The most common cause is a motor vehicle accident, followed by direct trauma and fall.

Epidemiology

The spleen is commonly injured in blunt abdominal trauma. Each year, an average of 25% (800 to 1200) admissions are for blunt trauma.

Pathophysiology

The spleen is a highly vascularized organ, and an injury to this organ can result in significant blood loss either from the parenchyma or the arteries and veins that supply the spleen. The spleen is an important lymphopoietic organ. The normal splenic function is necessary for the opsonization of encapsulated organisms.[5]

The spleen serves the following functions:

Hematologic Function

• Maturation of red cells
• Extraction of abnormal cells via phagocytosis
• Remove particulates such as opsonized bacteria, or antibody-coated cells from the blood

Immunologic Function

• Contribute to humoral and cell-mediated immunity

In adults, normal splenic size is up to 250 gm and up to 13 cm long. It involutes with age and is usually not palpable in adults. The spleen, in adults, is less pliable than in children.

History and Physical

The mechanisms most commonly described are trauma to the left upper quadrant, left rib cage, or left flank. However, the absence of these types of injuries cannot exclude the possibility of splenic injury.

Inquire about previous operations, including splenectomy. Other questions that doctors should explore are liver or portal venous disease, the use of an anticoagulant agent, bleeding tendency, and the use of aspirin or nonsteroidal anti-inflammatory agents.

The typical presentation includes left upper quadrant pain, abdominal distension, and hypotension. Left shoulder pain may occur due to diaphragmatic irritation.

Evaluate the abdomen for external signs of trauma such as abrasions, lacerations, contusions, and seatbelt sign. The absence of these external findings does not exclude intra-abdominal injury. Up to 10% to 20% of patients with intra-abdominal injury may not have these findings upon examination. An initial examination on arrival may not show tenderness, rigidity, or distention. Therefore, it may not be sufficiently sensitive nor specific enough to identify a splenic injury.

The presentation of splenic injury depends upon associated internal hemorrhage. Patients may present with hypovolemic shock manifesting tachycardia and hypotension. Other findings include tenderness in the upper left quadrant, generalized peritonitis, or referred pain in the left shoulder (Kehr's sign). This is a rare finding, which should increase the suspicion of splenic injury. Some patients may have pleuritic left-sided chest pain. Physical examination may be limited by decreased mental status or distracting injuries. Upon initial evaluation, a splenic injury that is contained may have few symptoms.

One should evaluate splenic injury if lower left rib (below the sixth rib) fractures are identified. In adults, up to 20% of patients with lower left rib fractures may have an associated splenic injury. However, in children, the plasticity of the chest wall can result in a severe underlying injury to the spleen in the absence of any rib fracture. One should suspect a pelvic fracture if the mechanism involves a high-energy blunt trauma. Also, one should consider bowel injuries in patients presenting with blunt splenic trauma, which occurs in less than 5% of patients initially thought to have an isolated organ injury.

Evaluation

Several adjuncts can be used to identify a splenic injury.[6][7]

Focused Assessment with Sonography for Trauma (FAST)

The focused assessment with sonography for trauma (FAST) examination can rapidly identify free intraperitoneal fluid in patients with blunt abdominal trauma. The FAST examination is particularly useful in the evaluation of hemodynamically unstable patients.

This examination consists of four acoustic windows (pericardiac, perihepatic, perisplenic, pelvic). FAST is considered positive if the fluid is identified as an anechoic band or a (black) rim around the spleen. Ultrasound is a sensitive modality to identify hemoperitoneum. However, it is important to remember that an intraperitoneal hemorrhage is not always present, especially when the splenic capsule remains intact. Up to 25% of splenic injuries do not exhibit intraperitoneal hemorrhage. Hemodynamic instability in the presence of free fluid on FAST examination requires rapid surgical evaluation and immediate laparotomy.

Certain injuries, such as intraperitoneal injuries involving bowel and mesentery and retroperitoneal organ injuries, may not be identified by the FAST exam due to the presence of hemoperitoneum.

Computed Tomography (CT)

The CT scan is the diagnostic modality of choice for detecting solid organ injuries. CT scans may show disruption in the normal splenic parenchyma, surrounding hematoma, and free intra-abdominal blood. CT scan is also useful in identifying solid organ vascular injuries. A contrast-enhanced CT scan should be obtained to determine the density difference between the splenic parenchyma and hematoma. This will also identify associated injuries. It is important to obtain good imaging as the suboptimal scan may result in a missed diagnosis of subtle splenic injuries.

Treatment / Management

The initial management of the trauma patient with splenic injury should follow the ABCs (airway, breathing, and circulation) of trauma resuscitation. The assessment of circulation during the primary survey includes early evaluation of the possibility of hemorrhage in patients with blunt trauma. It is important to assess whether the patient is in early shock and provide prompt resuscitation. Beware that there is a possibility of concomitant hollow viscus injury in patients with solid organ injury.[8][9][10]

Spleen Organ Injury Scale

Splenic injury is classified based on CT findings according to the American Association for the Surgery of Trauma (AAST) Organ Injury Scale. It is a useful scale that categorizes splenic injuries, but it does not predict the need for surgical intervention.

Grade 1

• Hematoma, subcapsular, less than 10% surface area
• Laceration, capsular tear, less than 1 cm parenchymal depth

Grade 2

• Hematoma, subcapsular, 10% to 50% surface area
• Intraparenchymal, less than 5 cm in diameter
• Laceration, capsular tear, 1 cm to 3 cm parenchyma depth that does not involve a trabecular vessel

Grade 3

• Hematoma, subcapsular,  more than 50% surface area expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma 5 cm or greater and expanding
• Laceration greater than 3 cm parenchymal depth or involving trabecular vessels

 Grade 4

• Laceration, laceration involving segmental or hilar vessels producing major devascularization ( more than 25% of the spleen)

Grade 5

• Laceration, completely shattered spleen
• Vascular; a hilar vascular injury that devascularizes the spleen

This CT grading may not always correlate with the grading of the injury as identified with surgical exploration. This may be due to technical issues and variability of the CT scan interpretation.

Hemorrhaging from a splenic injury can be ongoing at the time of presentation or may have stopped. Injuries in which bleeding has ceased can be managed without splenectomy, although patients may develop delayed hemorrhaging. Delayed splenic rupture may occur up to 10 days following an injury. The rate of late bleeding may occur up to 10.6% of the time, but it varies with the grade rating of the splenic injury. Therefore, a careful selection of patients should be performed, and make sure that one closely monitors these patients, and a serial abdominal examination should be performed.

Non-operative Management of Splenic Trauma

Treatment of splenic injury is aimed to maximize salvage therapy. In children, the use of non-operative management of hemodynamically stable patients has become the standard of care. Up to 80% of blunt splenic injuries can be managed non-operatively. It has been increasingly used in adults, and age has not influenced the outcome of non-operative management of blunt splenic trauma.

However, it should be considered only in a hemodynamically stable patient without signs of peritonitis. It is important that only patients who are stable and have no evidence of ongoing blood loss should be selected for non-operative management.

Non-operative management has been attempted in high-grade injuries as long as the patient remains hemodynamically stable without evidence of active bleeding. These patients should be hospitalized in a center where a pediatric surgeon is available for close observation and a series of multiple examinations. In this situation, the option of surgical intervention must be available at all times.[11][12]

Patients who require transfusions involving more than two units of blood, or show signs of ongoing bleeding, should be considered for operative management or embolization.

Operative Management

Operative intervention and splenectomy remain life-saving events for many patients. The decision for surgical intervention depends on the clinical or hemodynamic status and the results of imaging studies. These include:

• Hemodynamic instability, which the majority of trauma surgeons consider an indication for emergent splenectomy in blunt trauma to the spleen
• Peritonitis
• Pseudoaneurysm formation
• Associated intra-abdominal injuries that require surgical exploration (bowel injuries)

Embolization

Splenic embolization requires specialized imaging facilities and a vascular interventionist. The following are guidelines for embolization in spleen trauma patients:

• Grade 3 or higher splenic injury
• Contrast blush on CT scan
• Moderate hemoperitoneum
• Evidence of ongoing bleeding

Prophylactic angioembolization in patients with splenic trauma, active arterial blush on CT, and stable hemodynamics are not indicated.

The complication rate is up to 35%. The following are common complications:

• Splenic infarction is devascularization of more than 25% of the spleen, which may occur in up to 20% of patients after embolization
• Re-hemorrhage
• Abscess

Differential Diagnosis

• Liver laceration
• Retroperitoneal bleeding
• Diaphragmatic injury
• Pancreas injury

Prognosis

In general, the physiologic stability of the patient is the major predictor of successful nonoperative management. Also, a CT-based grading system has shown successful observation in patients with blunt splenic injury. Overall, patients with low-grade splenic injury managed conservatively have good outcomes. But those who undergo spleen removal are always at risk for infection.

Complications

• Delayed splenic rupture; Although rare, it can occur up to 10 days after injury. This is perhaps associated with subtle low-grade injury to the spleen, which may not have been identified on imaging studies.
• Readmission for bleeding
• Splenic artery pseudoaneurysm
• Post-splenectomy infection: the risk is high in the first five years of life but can occur at any time.
• Splenic abscess
• Pancreatitis
• Death

Postoperative and Rehabilitation Care

Post-splenectomy patients should receive vaccinations for encapsulated bacteria before discharge from the hospital.

Prophylactic antibiotics are also recommended.

Consultations

Trauma team activation or early surgical service involvement is important.

Pearls and Other Issues

Patients who undergo splenectomy are at a higher risk of infection and overwhelming sepsis. Therefore, post-splenectomy vaccines should be administered to ensure their protection from encapsulated bacteria, which include Streptococcus pneumoniae, Neisseria meningitidis, and Hemophilus influenzae.

Children receive penicillin V (250 mg/day) for at least two years, and life-long antibiotic therapy is recommended for high-risk patients.

Beware that patients with splenic injuries may worsen during the hours or days following initial trauma and should be carefully monitored.

Caution: Since the contrast agent diffuses relatively slowly through the pulp of the spleen and may appear as a defect in enhancement, these may be misinterpreted as splenic injury.

Enhancing Healthcare Team Outcomes

The management of splenic trauma must be with an interprofessional team that includes physicians, nurses, radiologists, intensivists, and laboratory personnel. One must always be aware of the physiological and immunological derangements that may occur with splenic trauma. While most patients are now managed conservatively with observation, close monitoring is vital. ICU nurses play a vital role in the monitoring of splenic injury. The abdomen must be examined carefully, and a serial CBC must follow. Any signs of hemodynamic stability should be reported to the surgeon.

Besides regular physical exams, the patient's hematocrit requires monitoring, and serial CT scans may be required. If the patient is monitored in an outpatient setting, they should be educated on the symptoms of bleeding and the need to urgently go to the nearest emergency room. For those who undergo splenectomy, there is always the risk of sepsis. Hence, the pharmacist should educate the patient on post-splenectomy sepsis. Also, the patient must be told to seek immediate assistance if they spike a fever. Finally, these individuals must be told to avoid traveling to areas where mosquito bites are endemic because, without a spleen, even a minor infection can quickly become life-threatening. Patients who have had their spleen removed must wear a medical alert bracelet.[13][14][15] [Level 5]

Outcomes

Today, splenectomy after trauma is rare; it is even rare to perform a splenectomy 24 hours later. After the initial observation of 24 hours, the patient may still require close observation as an inpatient or outpatient for two weeks. The majority of these patients have an excellent outcome in the long run. Further, even in patients who bleed later, selective arterial embolization has replaced splenectomy because it has a very high success rate.[2][16] [Level 5]

Review Questions

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References

1.

Dickinson CM, Vidri RJ, Smith AD, Wills HE, Luks FI. Can time to healing in pediatric blunt splenic injury be predicted? Pediatr Surg Int. 2018 Nov;34(11):1195-1200. [PubMed: 30194477]

2.

Boyle TA, Rao KA, Horkan DB, Bandeian ML, Sola JE, Karcutskie CA, Allen C, Perez EA, Lineen EB, Hogan AR, Neville HL. Analysis of water sports injuries admitted to a pediatric trauma center: a 13 year experience. Pediatr Surg Int. 2018 Nov;34(11):1189-1193. [PubMed: 30105495]

3.

Zarzaur BL, Rozycki GS. An update on nonoperative management of the spleen in adults. Trauma Surg Acute Care Open. 2017;2(1):e000075. [PMC free article: PMC5877897] [PubMed: 29766085]

4.

Yang K, Li Y, Wang C, Xiang B, Chen S, Ji Y. Clinical features and outcomes of blunt splenic injury in children: A retrospective study in a single institution in China. Medicine (Baltimore). 2017 Dec;96(51):e9419. [PMC free article: PMC5758268] [PubMed: 29390566]

5.

Echavarria Medina A, Morales Uribe CH, Echavarria R LG, Vélez Marín VM, Martínez Montoya JA, Aguillón DF. [Associated factors to non-operative management failure of hepatic and splenic lesions secondary to blunt abdominal trauma in children]. Rev Chil Pediatr. 2017;88(4):470-477. [PubMed: 28898314]

6.

Coccolini F, Montori G, Catena F, Kluger Y, Biffl W, Moore EE, Reva V, Bing C, Bala M, Fugazzola P, Bahouth H, Marzi I, Velmahos G, Ivatury R, Soreide K, Horer T, Ten Broek R, Pereira BM, Fraga GP, Inaba K, Kashuk J, Parry N, Masiakos PT, Mylonas KS, Kirkpatrick A, Abu-Zidan F, Gomes CA, Benatti SV, Naidoo N, Salvetti F, Maccatrozzo S, Agnoletti V, Gamberini E, Solaini L, Costanzo A, Celotti A, Tomasoni M, Khokha V, Arvieux C, Napolitano L, Handolin L, Pisano M, Magnone S, Spain DA, de Moya M, Davis KA, De Angelis N, Leppaniemi A, Ferrada P, Latifi R, Navarro DC, Otomo Y, Coimbra R, Maier RV, Moore F, Rizoli S, Sakakushev B, Galante JM, Chiara O, Cimbanassi S, Mefire AC, Weber D, Ceresoli M, Peitzman AB, Wehlie L, Sartelli M, Di Saverio S, Ansaloni L. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg. 2017;12:40. [PMC free article: PMC5562999] [PubMed: 28828034]

7.

Zarzaur BL, Dunn JA, Leininger B, Lauerman M, Shanmuganathan K, Kaups K, Zamary K, Hartwell JL, Bhakta A, Myers J, Gordy S, Todd SR, Claridge JA, Teicher E, Sperry J, Privette A, Allawi A, Burlew CC, Maung AA, Davis KA, Cogbill T, Bonne S, Livingston DH, Coimbra R, Kozar RA. Natural history of splenic vascular abnormalities after blunt injury: A Western Trauma Association multicenter trial. J Trauma Acute Care Surg. 2017 Dec;83(6):999-1005. [PubMed: 28570347]

8.

Belli AK, Özcan Ö, Elibol FD, Yazkan C, Dönmez C, Acar E, Nazlı O. Splenectomy proportions are still high in low-grade traumatic splenic injury. Turk J Surg. 2018;34(2):106-110. [PMC free article: PMC6048652] [PubMed: 30023973]

9.

Gaarder C, Gaski IA, Næss PA. Spleen and liver injuries: when to operate? Curr Opin Crit Care. 2017 Dec;23(6):520-526. [PubMed: 29016365]

10.

Hughes J, Scrimshire A, Steinberg L, Yiannoullou P, Newton K, Hall C, Pearce L, Macdonald A. Interventional Radiology service provision and practice for the management of traumatic splenic injury across the Regional Trauma Networks of England. Injury. 2017 May;48(5):1031-1034. [PubMed: 28292519]

11.

Kohler JE, Chokshi NK. Management of Abdominal Solid Organ Injury After Blunt Trauma. Pediatr Ann. 2016 Jul 01;45(7):e241-6. [PubMed: 27403671]

12.

Notrica DM, Eubanks JW, Tuggle DW, Maxson RT, Letton RW, Garcia NM, Alder AC, Lawson KA, St Peter SD, Megison S, Garcia-Filion P. Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE. J Trauma Acute Care Surg. 2015 Oct;79(4):683-93. [PubMed: 26402546]

13.

Tugnoli G, Bianchi E, Biscardi A, Coniglio C, Isceri S, Simonetti L, Gordini G, Di Saverio S. Nonoperative management of blunt splenic injury in adults: there is (still) a long way to go. The results of the Bologna-Maggiore Hospital trauma center experience and development of a clinical algorithm. Surg Today. 2015 Oct;45(10):1210-7. [PubMed: 25476466]

14.

Koo M, Sabaté A, Magalló P, García MA, Domínguez J, de Lama ME, López S. [Multidisciplinary protocol for computed tomography imaging and angiographic embolization of splenic injury due to trauma: assessment of pre-protocol and post-protocol outcomes]. Rev Esp Anestesiol Reanim. 2011 Nov;58(9):538-42. [PubMed: 22279872]

15.

Schuster T, Leissner G. Selective angioembolization in blunt solid organ injury in children and adolescents: review of recent literature and own experiences. Eur J Pediatr Surg. 2013 Dec;23(6):454-63. [PubMed: 24327220]

16.

Armstrong RA, Macallister A, Walton B, Thompson J. Successful non-operative management of haemodynamically unstable traumatic splenic injuries: 4-year case series in a UK major trauma centre. Eur J Trauma Emerg Surg. 2019 Oct;45(5):933-938. [PubMed: 29909466]

Disclosure: Muhammad Waseem declares no relevant financial relationships with ineligible companies.

Disclosure: Scott Bjerke declares no relevant financial relationships with ineligible companies.