Ruptured Spleen

Even though the spleen is protected beneath the bony ribs, it remains the most commonly ruptured organ in the abdomen when blunt trauma afflicts the area. These accidental injuries can be found in urban and rural environments, resulting from motor vehicle accidents, sports injuries, domestic violence and bicycle injuries.

What is a Ruptured Spleen?

Weighing in at 75-150 grams, the spleen is highly vascular and is an organ that filters the blood of abnormal blood cells and impurities. It filters approximately 10-15 percent of the blood volume each minute and holds around 50 milliliters of red blood cells in reserve at any given point in time but can pool blood to a greater degree because it is relatively pliable. As many as 25 percent of the platelets circulating in the body are stored in the spleen.

While it is protected under the bony rib cage, the spleen is the most likely solid organ of the abdomen to rupture. It can rupture from bony trauma or from errors in surgery place the spleen in a fixed position in the body due to preexisting adhesions.

Certainly, penetrating trauma can also damage the spleen.

Rupture of the spleen carries the risk of excessive bleeding because the spleen is so vascular. This is especially true if the spleen is enlarged due to a blood disorder.

Historically, the spleen was always removed after a rupture but now that CT scanning has been developed, the amount and change in bleeding over time can be evaluated so that conservative measures can be taken when a spleen ruptures, preserving the immunological function of the spleen. This technology has made it safe to watch a splenic rupture to see if it heals on its own. This is especially true of very young and very old patients. There are still deaths due to splenic rupture so that they need to be managed at level I trauma centers.

It’s not clear exactly what the actual frequency of splenic injuries is as hospital discharge diagnoses may not clearly state that a splenic injury has occurred if more serious injuries have happened. It is estimated that about 25 percent of blunt trauma injuries to the abdomen involve a splenic rupture. There are a total of 800-1200 blunt trauma injuries to the abdomen each year. This doesn’t take into account those splenic ruptures that are treated at non-trauma centers.

Penetrating trauma to the spleen is far below that which is seen in the large and small intestines. There is a third type of injury in splenic trauma and that combines blunt trauma and penetrating trauma in warfare and some civilian bombing attacks. These are explosive types of injuries.

Injuries to the spleen occur due to rapid deceleration as in an automobile accident or due to a direct blow to the area of the spleen in domestic violence and in leisure activities like biking and other sports-related injuries.

There have been increasing reports of splenic damage after a colonoscopy. A recent study found that 66 patients aged around 65 years were documented, yielding a 4.5 percent mortality rate. Most of them occurred during what was an uneventful colonoscopy screening test. Symptoms of splenic trauma usually showed up within 24 hours of the injury; CT scanning was done to confirm the splenic injury in about 94 percent of cases.

Over half of patients affected by splenic trauma following colonoscopies underwent a laparotomy and removal of the spleen. Common finding included a splenic hematoma in 47 percent of cases, a splenic laceration in 47 percent of cases and splenic rupture in 33 percent of cases. It was determined that, because of the rising number of colonoscopies, more of these injuries are likely to happen.

There are diseases that increase the risk for getting a ruptured spleen. These include having infectious mononucleosis. Sometimes a ruptured spleen is the first indication that the person has a case of mono. Hemolytic anemia and certain kinds of lymphoma indicate you have a higher risk of getting a ruptured spleen. Patients with malaria are at a greater risk.

What causes a Ruptured Spleen?

When the capsule of the spleen ruptures, the end result can be an immediate medical catastrophe. A large amount of blood leaks into the abdominal cavity and this results in pain and potential shock. It is caused by a great blunt trauma or penetrating trauma to the spleen. In some cases, the splenic capsule protects the spleen from actually rupturing.

Certain diseases can also cause the spleen to rupture with even the most minor injury. These include diseases that swell the spleen so that the capsule becomes too thin. They include certain types of blood cancers, metabolic disorders, infections, and certain liver diseases including cystic fibrosis and cirrhosis. The spleen becomes large and is a bigger target with a lesser degree of protection than if it is normal sized.

What are the symptoms of Splenic Injury?

When a patient has a ruptured spleen, the clinical presentation is variable. A mild injury might show up as left upper quadrant abdominal tenderness. Left shoulder pain is possible because of the vagus nerve inflammation and pain that is referred to the shoulder.

If there is free-flowing blood to the intraperitoneal area, there can be diffuse abdominal pain, irritation of the peritoneum and rebound tenderness. If the amount of blood in the abdomen exceeds 5-10 percent of the total blood volume, early shock symptoms can show up. These can include tachypnea, tachycardia, anxiety and restlessness. They may also have a mild pallor.

Doctors will note that there is decreased capillary refill, abdominal distension, peritoneal signs, decreased pulse pressure and finally overt shock.

Low blood pressure in someone who has suspected splenic injury, especially if they are previously healthy, will soon become a surgical emergency and a sign of grave injury. This means there should be an immediate evaluation of the situation and intervention in the operating room and in the interventional radiology department.

Unstable patients, on the other hand, have exsanguinated in the CT scanner due to being worked up for ruptured spleen. Exploration in the operating room is perhaps the best option.

The pain of a ruptured spleen is usually severe but if it is a mild rupture, the pain can be minor. It all depends on the degree of blood leakage and the rate of blood leakage from the spleen. The pain initially is felt on the left upper side of the abdomen and then spreads to involve the left upper shoulder or the entire abdomen.

The blood pressure can drop quickly or slowly. This can result in blurry vision, confusion, fainting spells, light-headedness or signs of shock.

How is a Ruptured Spleen Diagnosed?

If a doctor suspects that a ruptured spleen has taken place, he or she can order one or two different diagnostic tests that can clarify the status of the spleen. It all starts with a physical examination. The doctor pushes on the abdomen, especially in the left upper quadrant to see if there is any pain or rebound tenderness.

Then the doctor can perform a “diagnostic peritoneal lavage”. This is where fluid is pumped into the abdomen through a needle and catheter. The abdominal contents are swished around to mix up any blood that might be in the abdomen. Then the fluid is drawn back out. If there is blood mixed with peritoneal fluid, it means something in the abdomen has been ruptured or punctured and usually means a surgeon should do a diagnostic laparotomy to check via surgery exactly where the bleeding is coming from.

If the patient’s vital signs are stable, the doctor may have time to do a CT scan of the abdomen. CT scans pick up areas of blood where they don’t belong and will pick up a ruptured spleen. It is important to recognize whether or not the patient is stable before proceeding with the CT scan. People have passed away while waiting for or receiving their CT scan due to instability of their situation.

In some cases, a contrast medium is introduced prior to a CT scan. The contrast medium can tell how much blood is being lost from a rupture in the spleen. It is perhaps the best test to see if anything is bleeding from the spleen or other solid abdominal organ. Without the contrast medium, bleeding may not show up at all.

Contrast dye should be avoided in those people who have been known to be allergic to it.

An ultrasound can diagnose a ruptured spleen. Ultrasounds detect free fluid from bleeding in the abdomen. Ultrasounds might be able to detect the actual area of damage to the splenic capsule. Plain x-rays might be able to detect free fluid and an irregular area in the spleen indicative of a rupture and might be able to show bony injuries in the area of the spleen.

Another test is called a focused abdominal sonographic technique or “FAST”. This is a method that uses ultrasound to check for fluid buildup in the abdomen. It is a faster test than a CT scan and therefore can be done in patients who are more unstable. It is a great test but not as accurate as a CT scan.

An MRI of the abdomen is a test that can be used for patients who have severe allergies to contrast dye used in CT scans or who have kidney failure that cannot take contrast dye. The MRI scan can take a while so that the patient must be very stable in order to have one. Vital signs must be taken periodically to rule out extremely fast blood loss. A hemoglobin can be done while waiting for the test.

Treating a Ruptured Spleen

The treatment of a ruptured spleen can be operative or nonoperative. Now that doctors have a better idea of the importance of the spleen, the trend in management has been in favor of conservative or nonoperative treatment of a splenic rupture.

Patients with stable vital signs but a known ruptured spleen are watched to see that the spleen heals on its own. If the bleeding stops and the capsule heals over, the patient can be discharged with a spleen that is at least partially functioning.

If a patient has a stable hemoglobin over 48 hours and had 2 units of bloods or less following the injury, they may be a good candidate for conservative management of their rupture. This is also true if the CT scan revealed grade 1 or 2 bleeding and if the patient is less than 55 years of age. Patients who are on anticoagulants are at risk for having acute and delayed bleeding but if they remain stable, they can consider undergoing conservative management of the injury.

Recombinant factor VIIa is a medication used to try and avoid having to do surgery in kids with splenic rupture. Because there has not been enough research on this factor in splenic rupture, it should be used only in those situations where surgery is risky and does not outweigh the benefits of giving the recombinant factor.

The patient can undergo what’s called interventional radiology. The exact procedure is called a splenic angioembolization. It can be used on those that are stable and those that are temporarily stable. The body is accessed through the femoral artery and the splenic artery is embolized, effectively stopping the bleeding. Any of the branches of the splenic artery can be embolized as well. Gel foam or metal coils are used to stop the flow of blood in the arteries. Not all facilities will have the proper equipment for a splenic angioembolization but those that do can act rapidly to achieve embolization rather than a complete surgery.

Surgical treatment of a splenic rupture is attempted whenever there are patient signs of profuse bleeding with hemodynamic instability. If the CT scan shows a grade V hemorrhaging injury and the patient is showing signs of instability, then observation is probably not a good idea and surgery should be performed. The patient will usually have an exploratory laparotomy to see exactly how much bleeding is happening and whether or not the spleen can be repaired or must be removed.

The surgery is done through a midline abdominal incision. The abdomen, including the spleen, is explored. This midline incision is the fastest way to open the patient and is the best way to look at all the abdominal organs and the viscera in a trauma situation, where anything can be damaged or injured and bleeding.

The ligaments holding the spleen to the body are taken down so that the splenic artery and vein can be localized. Then the splenic artery and vein are ligated and the short gastric arteries and veins are given the same treatment. The spleen needs to be pulled out and rotated in order to see all these vessels. The splenic artery is ligated first and the splenic vein is ligated second. When all vessels have separated the spleen from the body, drains are placed in the body in the left upper abdominal and flank area so as to be able to drain out blood that has been left in the body. They are removed several days later.

If the situation isn’t that severe and there is just a tear in the capsule of the spleen, a splenorrhaphy is performed. This procedure can remove part of the spleen or can stitch up the tear in the spleen. Selective small arteries can be ligated and an absorbable mesh bag can cinch up the torn spleen and absorbs as the spleen heals.

Sometimes an electrocautery machine is used to stop spots of bleeding within the spleen. This can easily preserve as much of the spleen as possible.

If the injury to the spleen is treated conservatively, the patient will be watched in the hospital for several days until the vitals are stable and a test has shown that the bleeding in the spleen has stopped. When this happens, you can be discharged to bed rest at home. It may be many weeks before it is safe for you to do sports activities or other activities on your own.

Complications of a Ruptured Spleen

Most people recover well after a splenic rupture. If the spleen rupture is grade I or grade II, the patient recovers well. Complications seem to increase if the spleen injury is severe or if the patient is greater than 55 years of age. People have died from major splenic injuries, even if the patient is treated at a large trauma center.

A person can live without a spleen but, in reality, the spleen plays a real role in the body’s ability to fight off certain kinds of bacteria. A person without a spleen will be placed at a greater risk of coming down with life-threatening bacterial infections.

When the spleen is removed, the patient should get a vaccination for Pneumococcus, Meningococcus and Haemophilus.

Children who have had a splenectomy should take antibiotics each and every day in order to prevent them from getting serious infections. Adults with a splenectomy do not need to take antibiotics daily but if they get sick, antibiotics are often necessary. Both kids and adults should wear a medic alert bracelet.

If you or a loved one has suffered a ruptured spleen as a result of someone else's negligence and would like to discuss your legal options with an experienced Sacramento Personal Injury Attorney, contact us online or call us at 916-921-6400 or toll-free at 800-404-5400 to set up a FREE consultation.

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