Introduction
The spleen is one of the most commonly injured intra-abdominal organs. Diagnosis and prompt management are key to success and their goal is to avoid potentially life-threatening haemorrhage.
The preservation of functional splenic tissue is secondary as usually the attempt to save the spleen is abandoned due to an ongoing hemorrhage that is life-threatening. Emergent and urgent splenectomy remains a life-saving measure for many patients.
The spleen is located posterolateral in the left upper quadrant of the abdomen beneath the left hemidiaphragm and lateral to the greater curvature of the stomach.
Mechanism of injury
Splenic injury most commonly occurs following blunt trauma due to motor vehicle collisions (driver, passenger, or pedestrian). However, blunt splenic injury can also result from falls, sport-related activities, assault or iatrogenic injuries from surgical or endoscopic manipulation. In the latter case, the lesion is caused by a capsular tear, laceration from retraction devices or tension on the spleen.
Trauma evaluation
In these patients we perform initial resuscitation, diagnostic evaluation and management following the the Advanced Trauma Life Support (ATLS) protocols.
In the initial history and physical examination, the patient usually complains of a left upper abdominal, left chest or shoulder pain. They may also present with abdominal tenderness and peritoneal signs. It is also important to determine whether these patients have medical comorbidities requiring antiplatelet or anticoagulant medication as these may impact in management decisions.
When evaluating these patients, associated injuries need to be explored. Lower rib fractures, pelvic fractures, spinal cord injury and other visceral lesions might be present.
Diagnostic evaluation
Focused assessment with sonography for trauma patients (FAST) is a rapid examination that is performed as a screening test in trauma patients. A negative FAST exam does not exclude splenic injury. Signs of splenic injury include a black rim around the spleen which may indicate subcapsular fluid. Other signs are intraperitoneal fluid or fluid in the hepatorenal space.
CT-Scan findings
- Hemoperitoneum: When fluid collections around the spleen are identified in trauma patients this is highly suggestive of hemoperitoneum.
- Hypodensity: Parenchymal disruptions and also intraparenchymal or subcapsular hematomas are represented as hypodense regions.
- Contrast extravasation: When contrast extravasation is identified it normally implies active bleeding so an urgent intervention is indicated.
Splenic injury grading
The American Association for Surgery of Trauma (AAST) has an injury grading scale based on different finding that can be identified either on CT scan or intraoperatively.
- Grade 1: Subcapsular hematoma <10 percent surface area. Parenchymal laceration <1 cm in depth or capsular tear.
- Grade 2: Subcapsular hematoma 10 to 50 percent surface área. Parenchymal laceration 1 to 3 cm in depth.
- Grade 3: Subcapsular hematoma >50 percent of surface area; ruptured subcapsular or intraparenchymal hematoma. Parenchymal laceration >3 cm in depth.
- Grade 4: Any injury in the presence of a splenic vascular injury or active bleeding confined within splenic capsule. Parenchymal laceration involving segmental or hilar vessels producing >25 percent of devascularization
- Grade 5: Any injury in the presence of splenic vascular injury with active bleeding extending beyond the spleen into the peritoneum. Shattered spleen.
Non-operative management
Traditionally, the years the only option to treat patients with splenic lesions was to perform a surgical exploration but this approach has been changing in recent years and currently non-operative management is used to manage 50 to 70 percent of cases, typically in low-grade injuries.
This approach is based on the assumption that salvaging functional splenic tissue avoids the risk of surgical and anesthetic complications and postsplenectomy sepsis.
Observation
The first option in nonoperative management is observation. However, this requires a monitored care setting, either in an intensive care unit or in a lower unit depending on the capabilities of the hospital, the grade of splenic injury, and the severity of other injuries.
The duration of observation should be individualized based on the grade of the splenic injury and the patient’s clinical status. Most trauma surgeons recommend follow-up imaging. If observation fails, either splenic embolization or more commonly, operative management is required.
Splenic embolization
Splenic embolization requires specialized imaging facilities and a vascular interventionalist experienced in celiac artery catheterization and embolization techniques.
Surgery
Hemodynamically unstable traumatic patients, patients who are not candidates for nonoperative management, and patients in whom non-operative strategies fail require surgical exploration. When surgery is performed, splenic salvage depends on the severity of the lesion, the patient’s clinical status, and the associated injuries.
CONCLUSIONS
- Traumatic splenic injury is a life-threatening situation.
- In treatment of patients with splenic injury, initial resuscitation, diagnostic evaluation and management is based on protocols for trauma patients (ATLS).
- For the diagnosis, CT scan findings are splenic hypodensity, subcapsular or intraparenchymal hematoma, active intravenous contrast extravasation or hemoperitoneum.
- If the patient is hemodynamically unstable and the FAST exam is positive, immediate surgical exploration is required.
- Management of stable patients must be individualized.
