Ruptured Spleen

Original Editors - Nick Hansen & Ren Peterson from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Nicholaus Hansen, Taylor Hutchison, Vidya Acharya, Kim Jackson, Michael Flores, Lucinda hampton, Admin, Elaine Lonnemann, Claire Knott, 127.0.0.1, WikiSysop, Wendy Walker and Naomi O'Reilly  

Definition/Description 

The spleen is an organ of the lymphatic system located on the left side of your stomach (abdomen) under the rib cage and diaphragm in a region that is referred to as the left upper quadrant. In humans the spleen is about the size of a fist and its primary roles are filtering the body’s blood and helps to fight infection. It also serves a role in storing and releasing certain types of immune cells that mediate tissue inflammation 

Rupturing a spleen describes an emergency situation in which your spleen has developed a break in its surface. This is serious condition that can occur during a direct blow or trauma and without emergency treatment a ruptured spleen can cause life threatening internal bleeding. 

Prevalence

The prevalence of splenic ruptures are poorly documented but one study suggest that traumatic splenic ruptures are more likely to occur in males (2:1 male to female) with ages ranging from 18-34 years.

Infectious Mononucleosis – Annually in the United States there are appropriately 345 – 671 cases per 100,000. Typically involving school age children ages 13-19 years. Approximately 0.1% to 0.2% of the 345 – 671 cases in the United States will suffer from splenic ruptures. “Base on this figure, approximately 100 cases of ruptures may occur yearly in the US, only a few of which are reported.”

Characteristics/Clinical Presentation

Signs and symptoms of a ruptured spleen includes:
• Pain (usually severe but not always) in the upper left portion of the stomach (abdomen) or under rib cage
• Tenderness when you touch the upper left portion of the stomach (abdomen)
• Left shoulder pain-Kehr’s Sign

Kehr's sign (Hans Kehr (1862–1913), German surgeon] pain in the left shoulder caused by irritation of the  undersurface of the diaphragm by blood leaking from a ruptured spleen. The pain impulses are referred along the phrenic nerve supplying the diaphragm C3-C5 nerve distribution.
Internal bleeding due to a ruptured spleen can cause blood pressure to drop (hypotension). This can cause: 
• Blurred vision
• Confusion
• Light-headedness
• Fainting
• Signs of shock (cold clammy skin, pale, weak or rapid pulse)

It is strongly advised to seek immediate medical care if an injury is sustained coupled with pain in the left upper stomach (abdomen) region along with any of the above listed signs and symptoms. If severe injuries are untreated a ruptured spleen can be fatal.

Associated Co-morbidities

Common co-morbidities for traumatic splenic ruptures are hypertension, type II diabetes, and asthma. In a study involving 538 subjects, 25% suffered from one or more of the co-morbilities listed above.

Non-traumatic splenic ruptures can be associated with numerous conditions and diseases. Some of the most common include, lymphoma, cirrhosis of the liver, liver disease, pancreatic pathology, bone marrow disorders such as leukaemia, and blood clotting disorders.

Viral diseases that can lead to splenic rupture include mononucleosis, malaria, and in rare cases HIV

Other conditions that can lead to splenic include drug addiction, sickle cell disease, and prolonged use of blood thinners.

Medications

No medications are prescribed to heal severe splenic ruptures, there are medications and vaccines recommended post-surgical removal of the spleen (splenectomy) in severe injuries.

The Advisory Committee on Immunization Practices for the Centers for Disease Control and Prevention (CDC) and the Society of Surgery for the Alimentary Tract recommends all patients that undergo splenectomy receive:

• the pneumococcal polysaccharide vaccine
• meningococcal vaccination
• considered for the Hib vaccine
• annual influenza vaccine in addition to the pneumococcal, meningococcal, and Hib vaccines, because secondary bacterial infections can lead to severe disease in this patient population
• boosters for all the bacterial vaccines every 5 years

Diagnostic Tests/Lab Tests/Lab Values

The most common test used to diagnosis splenic rupture is computed tomography (CT) which can be supplemented by x-ray.

Grades of Splenic Injury

Grades	Extent of Splenic Injury
Grade 1	Hematoma; subcapular, non expanding, <10% of surface area Laceration: capsular tear, non bleeding, <1 cm of parenchymal depth
Grade 2	Hematoma, subcapular, non expanding, 10-50% of surace area, intraparenchyma, non expanding, <2 cm in diameter Laceration: capsular tear, active bleeding, 1-3 cm of parenchymal depth that does not involve a trabecular vessel
Grade 3	Hematoma: subcapular >50% of surface area or expanding, ruptured subscapuar hematoma with active bleeding, intraparenchymal hematoma, >2 cm or expanding Lacertation > 3 cm of parenchymal depth or involving trabecular vessels
Grade 4	Hematoma: ruptured intraparenchymal hematoma with active bleeding Laceration: laceration involving segmental or hilar vessel producing major devascularization (>25% of spleen)
Grade 5	Hematoma: completely ruptured spleen Laceration: hilar vascular injury that devacularizes spleen

Table Reference

Spleen, trauma. Chest radiograph shows a peripherally calcified mass in the left upper quadrant under the diaphragm. The mass represents a calcified splenic hematoma.

Spleen, trauma. Contrast-enhanced CT scan shows a localized area of dense contrast collection in the splenic hilum, with a massive amount of surrounding fluid/blood. Findings here are indicative of active extravasation of contrast in a patient with traumatic autosplenectomy. This is a grade V injury.

Grade I - Subcapsular hematoma of less than 10% of surface area. Capsular tear of less than 1 cm in depth.

Grade III - Subcapsular hematoma of greater than 50% of surface area or expanding and ruptured subcapsular or parenchymal hematoma. Intraparenchymal hematoma of greater than 5 cm or expanding. Laceration of greater than 3 cm in depth or involving trabecular vessels.

Grade V - Shattered spleen or hilar vascular injury

Etiology/Causes

Traumatic(common)
• Injury or blow to left side of the body (left upper abdomen or left lower chest)
• Sports related
• Fights/Assaults
• Motor vehicle accidents
• Falls

Atraumatic(uncommon and diagnosis is often missed due to absence of any history of trauma)

http://www.rcsed.ac.uk/journal/vol47_1/47100010.html

http://www.rcsed.ac.uk/journal/vol47_1/47100010.html

Systemic Involvement

Rupture of the spleen can lead to life threatening bleeding into the abdominal cavity, which will lead to low blood pressure and decreased oxygen supply to the heart and brain. It is a medical emergency and should be referred to the emergency room immediately.

Medical Management (current best evidence)

First case control study on operative vs. non-operative management by Upadhyaya and Simpson in 1968 suggested that isolated splenic injuries could be safely treated without surgery in children. Pediatric surgeons led the way during the following decades, and non-operative management is now reported to be successful in more than 90 percent of children with isolated blunt injuries.

Non-Operative Management (NOM)
• Non-operative management may require:
• Significant blood transfusions
• Repeated CT scans
• Hematocrits (a centrifuge for separating blood cells from plasma)
• Close observation for up to 2 weeks, including an initial period of observation in intensive care.

• Non-Operative treatment is attempted in 60-90% of patients with blunt traumatic splenic injuries with intent to preserve splenic function

• Spleen preserving surgery gained popularity in 1960’s due to the discovery of the spleens role in immune function

• Predictors and other risk factors associated with failure of non-operative management:

• Hemodynamic instability:
o systolic blood pressure less than 100 mm Hg
o heart rate greater than 120 beats per minute
o lack of response to a fluid challenge of 2 L of a crystalloid solution

•Contrast Extravasation:
o A leakage of contrast material into the fatty tissue around a vein. Contrast is a dye that allows your veins and arteries to show up more clearly on the CT/MRI scan

• Arteriovenous Fistula:
o abnormal connection between an artery and a vein

• Pseudoaneurysm:
o false aneurysm

• Large volume of blood in peritoneum cavity

• age over 55 years

• multiple injuries

• Angioembolization is an adjunct to non-operative management and generally reported to increase the success rate of non-operative management approaching 95 percent

http://onlinelibrary.wiley.com/doi/10.1002/bjs.7764/abstract

• In angiographic embolization, coils or pledgets are used to reduce splenic hemorrhage, by occlusion either of the proximal splenic artery or of more distal branches (Fig.2a,b). Proximal splenic artery embolization is thought to reduce the perfusion pressure in the spleen, thereby stopping bleeding and the risk of delayed rupture or rebleeding. Peripheral embolization stops bleeding more selectively and occludes pseudoaneurysms or arteriovenous fistulas

Operative Management (OM)
• Splenectomy
• Performed most splenic injuries up to 1950
• Complete removal of spleen
• Most appropriate procedure for unstable patients
• Laproscopic and Open procudures
• Prone to infections

•

• Splenorrhaphy
• Suturing the spleen and non-removal
• Performed approximately 6% of the time (anything new in adult splenic ruptures)
• Grade 3 spleen injury - mesh splenorrhaphy

http://www.trauma.org/index.php/main/images_keyword/laparotomy/

Physical Therapy Management (current best evidence)

Physical therapist must be able to recognize the signs and symptoms of spleen rupture.  In sports, splenic rupture is the most common cause of death due to abdominal trauma, it is vital that clinicians perform a through exam of the patient.

Palpation - The spleen is located in the left upper quadrant and covered by the 9th - 11th ribs. Clinicians should check this area for pain and tenderness.  Abdominal palpation should also be performed in the hook-lying position checking for tenderness, distension, guarding, and rebound tenderness. "To palpate the spleen, lift the left flank with your nondominant hand; keeping your other hand flat, depress the palpating digits just below and anteriro to the 11th  and 12 ribs and ask the patient to take a deep breath.  A normal healthy spleen should not be palpable."

Patient Education - Most splenic ruptures can be rapidly progressing, while others can delay hemmorrhage for hours, days, or even weeks after injury, until a suffient enough force causes rupture.  It is vital that we education patients about the signs and symptoms so they can seek medical care immediately.

Post-operation: encourage ROM, ambulation, and coughing techniques (splinted coughing). Most traumatic splenic ruptures will not be seen in physical therapy.

Differential Diagnosis

Left kidney trauma/pathology

Rib fracture

Intestinal pathology

Musculoskeletal Involvement

Case Reports/ Case Studies

Third-Degree Spleen Laceration in a Male Varsity Athlete

http://journals.humankinetics.com/att-back-issues/attvolume8issue3may

Splenic Rupture in Infectious Mononucleosis

http://www.annals.org/content/46/6/1184.short

Spontaneous rupture of the spleen – a fatal complication of pregnancy

http://www.ncbi.nlm.nih.gov/pubmed/7572867

Case Report

Philippe E. Fait, Richard DeMont. Third-degree spleen laceration
in a male varsity athlete. Athletic Therapy Today. 2003; 8; 32-33

Patient:
-23 year old male university hockey player "Eric"
-Collided with another player and then got up and skated to the bench but had extreme difficulty breathing
-They performed a bench and concussion evaluation and the player was deemed “winded” and cleared to play
-Not long after getting back out there he complained of general body pain
-They took him into the locker room where he immediately began vomiting

Physician Evaluation and Dx:
-no rib fractures
-Kehr’s sign= suspected spleen damage yet not 100% certain b/c he had prior shoulder surgery the previous year

Tests:
-Xray and then sent home

Next Day:
-Felt worse so parents took him back to hospital
-Admitted to intensive care dept
-CT revealed a 3rd degree spleen laceration

Care and Treatment:
-Usual conservative (nonsurgical) trx - 1 week hospitalization
-Prescribed a 6 month recovery before returning to hockey
-At 2 months-light to medium physical activity and a CT scan
-At 4 months- follow up assessment, intense physical noncontact training began
-At 6 months- full contact was permitted

Prognosis:
-At 5 months postinjury-
-engaged in regular gym workouts
-returned to a normal diet
-lost considerable weight

• Player continued a conservative approach to return to sport in that he decided to not to play varsity hockey the following season, taking at least 1 year off.
  
  

Resources

1. Mayo Clinic
http://www.mayoclinic.com/health/ruptured-spleen/DS00872

2. Medscape
http://emedicine.medscape.com/article/432823-treatment

3. Discussion Board Spleen Rupture
http://www.medhelp.org/tags/show/148977/rupture-spleen

http://www.healthboards.com/boards/general-health/698344-rib-cage-injury-ruptured-spleen.html

Recent Related Research (from Pubmed)

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References

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