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, WikiSysop, 127.0.0.1, 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 disruption in its surface or blood supply. This is a serious condition that can occur during a direct blow or trauma and without emergency treatment, a ruptured spleen can cause life -internal bleeding.

Prevalence

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

Infectious Mononucleosis also known as glandular fever can lead to a ruptured spleen. Annually in the United States there are appropriately 345 – 671 cases per 100,000. Typically involving school-age children aged 13-19 years. Approximately 0.1% to 0.2% of the 345 – 671 cases in the United States will suffer from splenic ruptures. “Based 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 include:

• 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) - 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.

• Video of Kehr’s Sign:

• Internal Bleeding occurs secondary to a ruptured spleen and can cause blood pressure to drop (hypotension). This can lead to: 
  • Blurred vision
  • confusion
  • Light-headedness
  • Fainting and signs of shock (cold clammy skin, pallor, nausea, vomiting, and weak and/or rapid pulse)

• Splenic Inflammation - This can be identified by performing the Castell’s Percussion Test: Patient is positioned in supine lying. The clinician palpates the left costal margin near the anterior axillary line and then instructs the patient to breathe normally while applying percussion at both full inspiration as well as at rest.
  • Findings: Positive test if the dull sound is present upon full inspiration and expiration. (Indicates spleen descending). Normal it is only dull at full inspiration and should be tympanic at rest. Important: If the spleen is found to be inflamed, DO NOT continue to palpate as it can lead to a rupture.

Clinical Pearl: 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 these comorbidities.

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.

Correlation with infectious mononucleosis:

• Splenomegaly can often be a primary symptom of Epstein Barr Virus (EBV).
• Splenic enlargement from the virus is associated with adenopathy as the virus places stresses on the immune system of which the spleen plays an important role.
• Incidence of trauma in the presence of a diagnosis of infectious mononucleosis places one with an increased risk of a ruptured spleen. 
• Signs and symptoms of infectious mononucleosis are:
  • Extreme fatigue
  • Fever
  • Sore throat
  • Head and body aches
  • Adenopathy
  • Splenomegaly
  • Dermatitis rash

• Clinicians should be aware of associated signs and symptoms of EBV infectious mononucleosis in order to refer out and provide the patient with proper medical treatment before a potential splenic rupture.

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:

• 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

• Blood tests such as a complete blood count to check the number of red blood cells, white blood cells and platelets in your system.
• Ultrasound or computerized tomography (CT) scan to help determine the size of your spleen and whether it's crowding other organs. This is the most common test used to diagnose a splenic rupture and can be supplemented by an x-ray.
  

CT Ruptured spleen

• Magnetic resonance imaging (MRI) to trace blood flow through the spleen

Grades of Splenic Injury

Grades	Extent of Splenic Injury
Grade 1	Hematoma: Subcapsular, non expanding, <10% of surface area Laceration: capsular tear, non-bleeding, <1 cm of parenchymal depth
Grade 2	Hematoma: Subcapsular, non expanding, 10-50% of surface area, intraparenchymaL, non expanding, <2 cm in diameter Laceration: Capsular tear, active bleeding, 1-3 cm of parenchymal depth not involving parenchymal vessel
Grade 3	Hematoma: subcapsular >50% of surface area or expanding, ruptured subcapsular hematoma with active bleeding, intraparenchymal hematoma, >2 cm or expanding Laceration > 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 devascularizes spleen

Table Reference

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

Aetiology/Causes

Traumatic (common)

• Injury or blow to left side of the body (left upper abdomen or left lower chest)
• Sports-Related
• Fights/Assaults/Domestic Violence
• Motor Vehicle Accidents
• Falls

Video demonstrating traumatic force required to rupture a spleen:
https://www.youtube.com/results?search_query=ruptured+spleen

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

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

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

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 an intensive care unit (ICU). 
• 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 1960s due to the discovery of the spleen's role in immune function. 
  

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

• Hemodynamic instability:
  • Systolic Blood Pressure less than 100 mm Hg.
  • Heart rate greater than 120 beats per minute. 
  • Lack of response to a fluid challenge of 2 L of a crystalloid solution.

• Contrast Extravasation:
  • 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:
  • Abnormal connection between an artery and a vein. 

• Pseudoaneurysm:
  • False Aneurysm
  • Large Volume of Blood in Peritoneal Cavity
  • Age Over 55 years 
  • Multiples Injuries
    

Angioembolization is an adjunct to non-operative management and generally reported to increase the success rate of non-operative management approaching 95 percent.  
In angiographic embolization, coils or pledgets are used to reduce splenic haemorrhage, 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

• Splenectomy:
  • Performed with most splenic injuries up to 1950
  • Complete removal of the spleen
  • Most appropriate procedure for unstable patients

• Laparoscopic and Open Procedures: 
  • 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

File:Splenorrhaphy.png

Physical Therapy Management

The 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 thorough examination 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 non-dominant hand; keeping your other hand flat, depress the palpating digits just below and anterior 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 haemorrhage for hours, days, or even weeks after injury until a sufficient enough force causes a rupture.  It is vital that we educate 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.

Video Link of Physical therapy management:

.

Differential Diagnosis

• Left kidney trauma/pathology
• Rib fracture
• Intestinal pathology
• Musculoskeletal Involvement
• Non-Hodgkin's Lymphoma 
• Infectious Mononucleosis 

Case Report/ Case Study

Spontaneous rupture of the spleen – a fatal complication of pregnancy