SPLEEN İNJURİES

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Definition
Definition
A splenic injury, which includes a ruptured spleen, is any injury
to the spleen. The rupture of a normal spleen can be caused by
trauma, such as a traffic collision.
SPLEEN
● 2nd most commonly injured solid organ in blunt injury
abdomen after liver
● Situated against 9-11 ribs
SURGICAL ANATOMY
● Developed from dorsal mesogastrium
● In children,necessary for both reticuloendothelial and RBC
production
● Pediatric spleen has thicker capsule and tough parenchymal
consistency which implies reduced need of operative intervention
● Adult spleen weight about 100-250g
SURGICAL ANATOMY
● Situated posteriorly left upper abdomen
● Covered by peritoneum except at the hilum Posterior and lateral
surface related to left hemidiaphragm and posterolateral lower
ribs
● Lateral surface attached through splenophrenic ligament
SURGICAL ANATOMY
● Posteriorly related to left iliopsoas muscle & left adrenal
glands
● Posteriormedial surface related to body & tail of pancreas
● Antromedially related to great curvature of stomach
● Inferiorly related to distal transverse colon & splenic flexure
● Lower pole attached to colon through splenicocolic ligament
● These attachments require devision during mobilisation
BLOOD SUPPLY
● Receives blood supply from celiac axis 1.spleenic artery
2.short gastric vessels that connect left gatroepiploic A. &
splenic circulation along greater curvature of stomach
BLOOD SUPPLY
● Drains through splenic vein & confluence with inferior mesentric
vein
● Through short gastric veins into left gastro epiploic vein
Spleen ruptured by trauma
Signs and symptoms
Signs and symptoms
In minor injuries with little bleeding, there may be abdominal pain,
tenderness in the epigastrium and pain in the left flank. Often there is
a sharp pain in the left shoulder, known as Kehr's sign.
Signs and symptoms
In larger injuries with more extensive bleeding, signs of hypovolemic
shock are most prominent. This might include a rapid pulse, low
blood pressure, rapid breathing, paleness, and anxiety.
Kehr's sign
Kehr's sign is the occurrence of acute pain in the tip of the shoulder
due to the presence of blood or other irritants in the peritoneal cavity
when a person is lying down and the legs are elevated. Kehr's sign in
the left shoulder is considered a classic symptom of a ruptured
spleen.May result from diaphragmatic or peridiaphragmatic lesions,
renal calculi, splenic injury or ruptured ectopic pregnancy.
Kehr's sign
Kehr's sign is a classic example of referred pain: irritation of the
diaphragm is signaled by the phrenic nerve as pain in the area above
the collarbone. This is because the supraclavicular nerves have the
same cervical nerves origin as the phrenic nerve, C3 and C4.
Kehr's sign
The discovery of this is often attributed to a German gall bladder
surgeon named Hans Kehr, but extensive studies into research he
conducted during his life shows inconclusive evidence as to whether
he actually discovered it.
Causes
Causes
The most common cause of a ruptured spleen is blunt abdominal
trauma, such as in traffic collisions or sports accidents. Direct,
penetrating injuries, for example, stab or gunshot wounds are rare.
Causes
Non-traumatic causes are less common. These include infectious
diseases, medical procedures such as colonoscopy, haematological
diseases, medications, and pregnancy. In less than one percent of cases
of infectious mononucleosis splenic rupture may occur.
Diagnosis
Diagnosis
Splenic rupture is usually evaluated by FAST ultrasound of the
abdomen. Generally this is not specific to splenic injury; however, it is
useful to determine the presence of free floating blood in the
peritoneum.
Diagnosis
A diagnostic peritoneal lavage, while not ideal, may be used to evaluate
the presence of internal bleeding a person who is hemodynamically
unstable. The FAST exam typically serves to evaluate the need to
perform a CT scan. Computed tomography with IV contrast is the
preferred imaging study as it can provide high quality images of the full
peritoneal cavity.
 Traumatic rupture of the
spleen on contrast enhanced
axial CT (portal venous
phase)
Splenic hematoma resulting
in free abdominal blood
Organ injury scale
American Association for the Surgery of Trauma Organ Injury
Scaling: Splenic Injury Grading
Treatment
Treatment
Because a splenic rupture permits large amounts of blood to leak into
the abdominal cavity, it can result in shock and death. Generally a
nonoperative approach is chosen in those who are hemodynamically
stable with non-worsening symptoms.
Treatment
During this period of nonoperative management strict bed rest
between 24–72 hours with careful monitoring along with a CT 7
days after the injury.
Treatment
If an individual's spleen is enlarged, as is frequent in
mononucleosis, most physicians will advise against activities
(such as contact sports) where injury to the abdomen could be
catastrophic.
Treatment
Patients whose spleens have been removed via a splenectomy
must receive immunizations to help prevent infections such as
pneumonia. This helps to replace the lost function of this organ.
Thank you