Ruptured Spleen

The spleen is a delicate, fist-sized organ under your left rib cage near your stomach. It contains special white blood cells that destroy bacteria and help your body fight infections. The spleen also makes red blood cells and helps remove, or filter, old ones from the body's circulation. A layer of tissue entirely covers the spleen in a capsule-like fashion, except where veins and arteries enter the organ. This tissue, called the splenic capsule, helps protect the spleen from direct injury.

What Is a Ruptured Spleen?

A ruptured spleen is an emergency medical condition that occurs when the capsule-like covering of the spleen breaks open, pouring blood into your abdominal area. Depending on the size of the rupture, a large amount of internal bleeding can occur. Your doctor may refer to a ruptured spleen as a "splenic rupture."

What Causes a Ruptured Spleen?

The spleen can rupture when the abdomen suffers a severe direct blow or blunt trauma. The spleen is the most frequent organ to be damaged in blunt trauma injuries involving the abdomen. That's true regardless of your age. The following are among the frequent causes of spleen injuries:

Motor vehicle accidents Injury during contact sports, such as football and hockey Bicycle accidents, such as falling into your bicycle's handlebars Domestic violence

Certain diseases and illnesses can also lead to a ruptured spleen. In such cases, the spleen becomes swollen and the capsule-like covering

becomes thin. This makes the organ especially fragile and more likely to rupture if the abdomen receives a direct hit (such as forceful football tackle). Diseases that increase the risk for a ruptured spleen include:

Infectious mononucleosis; in some cases, a ruptured spleen is the first sign of the illness. Blood (hematological) diseases such as hemolytic anemia and certain types of lymphoma. Malaria.

Recent studies have also linked colonoscopy, a procedure that looks at the large intestine, to an increased risk of a ruptured spleen.

Symptoms of a Ruptured Spleen

A ruptured spleen causes abdominal pain, usually severe, but not always. The severity and even the location of the pain depend on how badly the spleen has ruptured and how much blood leaks out. Pain may be felt in these locations:

Left side of the abdomen under the rib cage. Left shoulder, because nerves of the left shoulder and left side of the diaphragm originate from the same location and the rupture may irritate these nerves.

Internal bleeding due to the ruptured spleen can cause blood pressure to drop. This can cause:

Blurred vision Confusion Light-headedness Fainting Signs of shock, including restlessness, anxiety, and paleness

How Is a Ruptured Spleen Diagnosed?

A physical exam may be the only test done to diagnose a ruptured spleen. The doctor will feel the person's belly area. The abdominal area may feel hard and look swollen (distended) because it has filled with blood. If there has been a great deal of blood loss from the spleen, the patient may have low blood pressure and a rapid heart rate. Sudden low blood pressure in someone who is believed to have a spleen injury, particularly a young person, is a sign that the condition is especially severe, and emergency surgery is needed.

Medical Therapy
The trend in management of splenic injury continues to favor nonoperative or conservative management. This varies from institution to institution but usually includes patients with stable hemodynamic signs, stable hemoglobin levels over 1248 hours, minimal transfusion requirements (2 U or less), CT scan injury scale grade of 1 or 2 without a blush, and patients younger than 55 years. For instances in which patients have significant injury to other systems, surgical intervention may be considered even in the presence of the previously noted findings. Patients on anticoagulants, such as warfarin (Coumadin), and antiplatelet drugs, such as clopidogrel (Plavix), are clinically considered to be at an increased risk for delayed bleed, but this has not yet been confirmed in the surgical literature. Recombinant factor VIIa has been used to avoid surgery in a pediatric patient but in light of both the cost of the drug and the lack of randomized clinical trials should be used only in extreme circumstances where risk of surgery outweighs the risk of massive thrombosis.[10]

Interventional radiology Splenic angioembolization is increasingly being used in both stable responders and transient responders for fluid resuscitation under constant supervision by a surgeon with an operating room on standby. Femoral artery access with embolization of the splenic artery or its branches can be accomplished with gel foam or metal coils. Such treatment requires intimate cooperation between the trauma surgeon and the interventional radiologist. Not all hospitals will have the proper facilities for such treatment, and any surgeon contemplating splenic angioembolization for a patient should first make sure the hospital interventional radiology suite and personnel are set up for rapid response at any hour of the day.

Surgical Therapy
Surgical therapy is usually reserved for patients with signs of ongoing bleeding or hemodynamic instability. In some institutions, CT scanassessed grade V splenic injuries with stable vitals may be observed closely without operative intervention, but most patients with these injuries will undergo an exploratory laparotomy for more precise staging, repair, or removal. Adult surgeons may be more likely to operate in cases of splenic injury but less likely to transfuse than their pediatric surgical colleagues.[11] Emergency celiotomy for hemoperitoneum with suspected splenic injury is performed through a midline abdominal incision. Subcostal or chevron incisions do not provide the opportunity to easily explore the lower abdomen for a hemorrhage site and cannot be performed as rapidly as a midline incision under emergency circumstances. Intestinal and mesenteric injuries may be missed, or they may be difficult to repair appropriately with subcostal incisions. The splenic ligamentous attachments are taken down sharply or bluntly to allow for rotation of the spleen and the vasculature to the center of the abdominal wound and to identify the splenic artery and vein for ligation. Medial rotation also makes exposure of the hilum of the spleen easier and allows for possible identification of the splenic artery bifurcation. Once the splenic artery and vein are identified and controlled by ligation, the short gastric vessels are identified and ligated in similar fashion. Ligating the splenic artery first, followed by the splenic vein, has the theoretical advantage of allowing some conservation of intrasplenic blood. In an emergency life-threatening situation, the amount of blood conserved is not worth the

extra time it may take to isolate the vessels. Drains are typically unnecessary unless concern exists over injury to the tail of the pancreas during operation. In less emergent situations, splenorrhaphy is the preferred method of surgical care. Multiple techniques are described in the literature, but they all attempt to tamponade active bleeding either by partial resection and selective vessel ligation or by putting external pressure on the spleen via an absorbable mesh bag or sutures. Both "make it yourself" and commercial products are available for this purpose. In patients with capsular injury, the electrocautery or argon beam coagulator device may provide adequate hemostasis and allow for splenic preservation.

Intraoperative Details
Good communication with the anesthesiologist minimizes the chances for iatrogenically induced problems. Opening the midline fascia on entry into the belly often results in decreasing pressure on the damaged spleen and increased bleeding with hypotension. Keeping the anesthesiologist informed of surgical progress and actions can minimize potential complications of this nature. In most trauma situations, all 4 quadrants of the abdomen are packed with laparotomy pads, which are removed as the search for the bleeding site commences. Presence of a splenic injury on CT scan does not preclude the potential of a bleeding mesenteric tear, consequently, all patients should have a thorough examination of the abdomeneven if preoperative studies show an isolated splenic injury.

Complications
Complications of nonoperative care include delayed bleeding, splenic cyst formation, and splenic necrosis. Complications of splenorrhaphy include rebleeding and thrombosis of the residual spleen as well as complications related solely to the laparotomy. Complications of splenectomy include bleeding from short gastrics or splenic vessels and the most feared but most rare complication, infection by encapsulated organisms such as Pneumococcus. Material used for compression wrap of the spleen in splenorrhaphy is often woven and may mimic bubbles in an abscess on postoperative CT scans. Gel foam used for angioembolization may also falsely mimic an abscess on CT scans. Communication with the radiologist about the presence of splenic wrapping material on any postoperative CT scans will decrease the chance of this false-positive result. Accessory splenic tissue and reimplantation of splenic tissue have never been reliably proven to minimize the risk of postsplenectomy sepsis. Once the spleen has been removed, patients should be considered to be at risk for encapsulated organism infections for the rest of their lives. Shatz et al noted improved postoperative response to immunization at day 14, with subsequent studies showing no further improvement at day 28.[12, 13] Angioembolization of the spleen can result in noninfectiousrelated febrile events, sympathetic pleural effusions, and left upper quadrant abscesses. Femoral arteriovenous fistulas and iliofemoral pseudoaneurysms have also been reported.[14, 15]

Posttraumatic splenic pseudocysts are being reported more frequently now that nonoperative management has become the norm.[16] Optimal management is still unknown but probably requires partial or complete splenectomy to minimize morbidity and mortality. Splenic abscesses and pancreatitis with sterile abscesses are being reported more frequently with Gelfoam embolization and with more proximal embolization procedures.[17, 18] Thrombocytosis with platelet counts above 1 million/mm3 have been linked to thrombotic vascular events such as deep vein thrombosis, pulmonary embolus, or occlusive stroke. Although very little good data exist, many surgeons treat persistent thrombocytosis with a daily baby aspirin. Pancreatic injury, pancreatitis, subphrenic abscess, gastric distension, and focal gastric necrosis have also been reported after both angioembolization and splenectomy for trauma.