- Splenic injury can be either accidental or iatrogenic
- Most commonly associated with blunt trauma
- Often occurs in the presence of lower rib fractures
- May be common clinically apparent either early or delayed
- Delayed injury is usually due to rupture of subcapsular haematoma
- 20% of splenic injuries occur inadvertently during other abdominal operations
- In some patients spontaneous rupture can occur following trivial trauma
- Spleen is invariably abnormal due to, for example, malaria or infectious mononucleosis
Clinical feature
- Clinical features depend on:
- Degree of hypovolaemia
- Presence of associated injuries
- Clinical features range from left upper quadrant pain to shock and peritonitis
- 30 to 60% of patients have other assocaited intraperitoneal injuries
Grading
- Grade 1 – Minor subcapsular tear or haematoma
- Grade 2 – Parenchymal injury not extending to the hilum
- Grade 3 – Major parenchymal injury involving vessels and hilum
- Grade 4 – Shattered spleen
Management
- If cardiovascularly unstable requires resuscitation and early surgery
- If cardiovascularly stable consider either ultrasound or CT scan
- If isolated Grade 1 or 2 splenic injury may be suitable for conservative management
Surgical options
- Surgical management can involve either splenectomy or splenic repair
- Main benefit of retaining the spleen is the prevention of OPSI
- If splenic conservation attempted need to preserve more than 20% of tissue
Conservative management
- Overall 20-40% of patients are suitable for conservative management
- Children can often be managed conservatively as they have
- Increased proportion of low grade injuries
- Fewer multiple injuries
- Should be monitored in high dependency unit
- Require cardiovascular and haematological monitoring
- If successful patients should remain on:
- Bed rest for 72 hours
- Limited physical activity for 6 weeks
- No contact sports for 6 months
- Surgery needed if clinically hypovolaemic of they have a falling haematocrit
- Approximately 30% of patients fail conservative management
- Usually occurs within the first 72 hours of injury
- Failed conservative management often results in splenectomy
- Overall more spleens can often be conserved by early surgery
Picture provided by Luis Pinheiro, Hospital Saint Teotonio, Viseu, Portugal
Bibliography
Brasel K J, DeLisle C M, Olson C J, Bergstrom D C. Splenic injury: trends in evaluation and management. J Trauma 1998; 44: 283-286.
Dupuy D E, Raptopoulos V, Fink M P. Current concepts in splenic trauma. J Intensive Care Med 1995; 10: 76-90.
Pachter H L, Guth A A, Hefstetter S R, Spencer F C. Changing patterns in the management of splenic trauma: the impact of non-operative management. Ann Surg 1998; 227: 708-719.
Sander M N, Civil I. Adult splenic injuries: treatment patterns and predictive indicators. Aust NZ J Surg 1999; 69: 430-432. |