Splenic Trauma

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Splenic Trauma

Definition

Splenic trauma is physical injury to the spleen, the lymphatic organ located in the upper left side of the abdomen just under the rib cage. The spleen weighs between 75 and 150 grams (between 0.16 and 0.33 pounds) in adults.

Description

The spleen is an organ that produces white blood cells, filters the blood (10-15% of the total blood supply every minute), stores red blood cells and platelets, and destroys those that are aging. It is located near the stomach on the left side of the abdomen. A direct blow to the abdomen may bruise, tear or shatter the spleen. Trauma to the spleen can cause varying degrees of damage, the major problem associated with internal bleeding. Mild splenic subcapsular hematomas are injuries in which bleeding is limited to small areas on and immediately around the spleen. Splenic contusions refer to bruising and bleeding on and around larger areas of the spleen. Lacerations (tears) are the most common splenic trauma injuries. Tears tend to occur on the areas between the three main blood vessels of the spleen. Because of the abundant blood supply, splenic trauma may cause serious internal bleeding. Most injuries to the spleen in children heal spontaneously. Severe trauma can cause the spleen or its blood vessels to rupture or fragment.

Splenic trauma is more common in children than in adults. In general, children are prone to abdominal injuries due to accidents and falls and because their abdominal organs are less protected by bone, muscle and fat. Abdominal injuries including splenic trauma are the most common cause of preventable deaths in children.

Causes and symptoms

The most common cause of injury to the spleen is blunt abdominal trauma. Blunt trauma is often caused by a direct blow to the belly, car and motorcycle accidents, falls, sports mishaps, and fights. The spleen is the most commonly injured organ in blunt abdominal trauma; splenic injury occurs in nearly 25% of injuries of this type. Penetrating injuries such as those from stabbing, gunshot wounds, and accidental impaling also account for cases of splenic trauma, although far less frequently than blunt trauma.

In adults, ruptured spleens may have been preceded by conditions causing rapid splenic enlargement, such as infections, particularly those caused by the Epstein-Barr virus (EBV); cancer ; immune system disorders; diseases of the spleen; or circulatory problems. In a very few cases the spleen may be injured by a spell of violent coughing. This type of rupture is known as an atraumatic rupture.

A spleen that has become enlarged and fragile from disease is sometimes ruptured by a doctor or medical student in the course of palpating (feeling) the patient's abdomen, or damaged by a surgeon in the course of an operation on other abdominal organs.

Damage to the spleen may cause localized or general abdominal pain, tenderness, and swelling. Fractured ribs may be present. Splenic trauma may cause mild or severe internal bleeding, leading to shock and for which symptoms include rapid heartbeat, shortness of breath, thirst, pale or clammy skin, weak pulse, low blood pressure, dizziness, fainting, sweating. Vomiting blood, blood in the stools or urine, deterioration of vital signs, and loss of consciousness are other symptoms.

Diagnosis

The goal of diagnosis of all abdominal traumas is to detect and treat life-threatening injuries as quickly as possible. The physician will determine the extent of organ damage and whether surgery will be necessary while providing appropriate emergency care. Initial diagnosis consists of detailing all circumstances of the injury from the patient and bystanders as well as the close physical examination of the patient and measurement of vital signs. Blood tests, urinalysis, stool samples and x rays of the chest and abdomen are usually performed. Plain x rays may show abdominal air pockets that indicate internal ruptures, but are rarely helpful because they do not show splenic and intra-abdominal damage.

Several other diagnostic tests may be used for the noninvasive and accurate assessment of splenic damage: computed tomography scans (CT), of magnetic resonance imaging (MRI), radionuclide scanning, and ultrasonography. Ultrasonography—particularly focused abdominal sonographic technique (FAST)—has now become a standard bedside technique in many hospitals to check for bleeding in the abdomen. Imaging tests allow doctors to determine the necessity and type of surgery required. The CT scan has been shown to be the most available and accurate test for abdominal trauma. MRI tests are accurate but costly and less available in some hospitals, while radionuclide scanning requires more time and patient stability. Peritoneal lavage is another diagnostic technique in which the abdominal cavity is entered and flushed to check for bleeding. When patients exhibit shock, infection, or prolonged internal bleeding, exploratory laparoscopy is used for emergency diagnosis.

Treatment

Not long ago nearly all cases of splenic trauma were treated by laparoscopy, opening the abdomen, and by splenectomy, the surgical removal of the spleen. This approach resulted from the difficulty in assessing the severity of the injury, the potential dangers of shock and death, and the beliefs that the spleen healed poorly and that it was not an important organ. Nowadays, improved techniques of diagnosis and monitoring (particularly the introduction of CT scans), as well as understanding that removal of the spleen creates future risk of a lowered capacity to fight infection has modified treatment approaches. Research over the past two decades has shown that the spleen has high healing potential, and confirmed that children are more susceptible to infection after splenectomy (post splenectomy sepsis, PSS). PSS has a mortality rate of over 50% and standard procedure now avoids splenectomy as much as possible. Adult splenic trauma is treated by splenectomy more often than children's; for unknown reasons, the adult spleen more frequently spontaneously ruptures after injury. Adults are also less susceptible to PSS.

Nonoperative treatment

In nonoperative therapy, splenic trauma patients are monitored closely, often in intensive care units for several days. Fluid and blood levels are observed and maintained by intravenous fluid and possible blood transfusions. Follow-up scans may be used to observe the healing process.

Operative treatment

Splenic trauma patients require surgery when nonoperative treatment fails, when major or prolonged internal bleeding exists and for gunshot and many stab wounds. Whenever possible, surgeons try to preserve at least part of the spleen and try to repair its blood vessels.

Prognosis

The ample blood supply to the spleen can promote rapid healing. Studies have shown that intra-abdominal bleeding associated with splenic trauma stops without surgical intervention in up to two out of three cases in children. When trauma patients stabilize during nonoperative therapy, chances are high that surgery will be avoided and that spleen injuries will heal themselves. Splenic trauma patients undergoing diagnostic tests such as CT and MRI scans have improved chances of avoiding splenectomy and retaining whole or partial spleens.

KEY TERMS

Computed tomography (CT) scan— Computeraided x-ray examination that allows cross-sectional views of organs and tissues.

Laparoscope— An optical or fiberoptic instrument that is inserted by incision in the abdominal wall and is used to view the interior of the peritoneal cavity.

Laparoscopy— Procedure using a laparoscope to view organs, obtain tissue samples and perform surgery.

Magnetic resonance imaging (MRI)— Imaging technique using magnets and radio waves to provide internal pictures of the body.

Radionuclide scanning— Diagnostic test in which a radioactive dye is injected into the bloodstream and photographed to display internal vessels, organs and tissues.

Ultrasonography— Imaging test using sound waves to view internal organs and tissues.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Splenic Rupture." Section 11, Chapter 141 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Bjerke, H. Scott, MD, and Janet S. Bjerke, MSN. "Splenic Rupture." eMedicine June 19, 2002. 〈http://www.emedicine.com/med/topic2792.htm〉.

Dixon, E., J. S. Graham, R. Sutherland, and P. C. Mitchell. "Splenic Injury Following Endoscopic Retrograde Cholangiopancreatography: A Case Report and Review of the Literature." Journal of the Society of Laparoendoscopic Surgeons 8 (July-September 2004): 275-277.

Kara, E., Y. Kaya, R. Zeybek, et al. "A Case of a Diaphragmatic Rupture Complicated with Lacerations of Stomach and Spleen Caused by a Violent Cough Presenting with Mediastinal Shift." Annals of the Academy of Medicine, Singapore 33 (September 2004): 649-650.

Laseter, T., and T. McReynolds. "Spontaneous Splenic Rupture." Military Medicine 169 (August 2004): 673-674.