The spleen is the second most commonly injured solid organ of the abdomen, behind the liver. Historically speaking, the treatment of splenic injuries was to do a splenectomy, with the belief that the spleen was not important in any way. Now it is known that the spleen is important to the immune system and removal of the spleen that is injured is less often done.
The spleen is divided into “red pulp” and “white pulp”. The red pulp gets rid of aged red blood cells and filters out bacteria. The white pulp consists of lymphocytes which receive antigens from the red pulp in order to create antibodies against different bacteria. There are lymphocyte collections in the liver, intestinal tract, thymus, and skin, which can make up for some of that which is lost during the loss of the spleen.
Without the spleen, the red blood cell breakdown isn’t as much affected and the red blood cell count increases only slightly. The white blood cell functions of the spleen are harder to do without. The incidence of sepsis and pneumonia from encapsulated bacteria is much higher after a splenectomy when compared to those who have not had a splenectomy. It is estimated that you need at least 20-50 percent of your spleen function in order to be considered to have normal splenic function.
Children are better candidates for treating spleen injuries without surgery because they have a tougher outer capsule than adults that can contain the bleeding better than is seen in adults. In some cases, such as with infectious mononucleosis, the spleen can become enlarged and more prone to rupture in children.
The spleen is located in the back of the abdomen and is close to the left diaphragm, connected by a ligament, known as the splenophrenic ligament. It is located near the left side of the ribcage so rib fractures on the left side should alert the physician to the possibility of spleen injury. The spleen can also be injured by a knife or bullet injury. If the diaphragm on the left side of the body is injured, the spleen can be injured along with it.
There are also attachments between the stomach and the spleen, the pancreas and the spleen and the left kidney and the spleen. These things can be injured and, if the spleen has to be removed because of injury, these attachments must be severed in order to remove the spleen. The spleen is also attached to the transverse colon and there is a ligament that connects the two structures together.
The spleen gets its blood supply from the splenic artery. The splenic artery can be a single artery entering the spleen or can break off into many different branches before entering the spleen. All the branches must be cut and clipped off before the spleen can be removed. The drainage of blood from the spleen comes from the splenic vein, which can also have many different branches.
Injury to the Spleen
About 45 percent of those with a spleen injury require emergency surgery. This doesn’t mean that everyone has to have their spleen removed. The spleen can be repaired and the vessels that come and go from the spleen can be treated separately, sparing the spleen.
Some people can have delayed bleeding from the spleen that occurs days or weeks after the spleen injury. In such cases, the CT scan shows an injury to the spleen shortly after the trauma but the bleeding doesn’t occur until much later.
Most penetrating injuries of the spleen are treated surgically because they are associated with other injuries inside of the abdomen that need surgical attention. This doesn’t mean that the spleen has to be removed at the time of surgery. It may simply be observed to be injured or parts of the spleen can be repaired without actually removing the spleen.
If a CT scan shows injury to the spleen, it is likely that other parts of the abdomen are injured as well. Areas that can be injured are the pancreas and the left side of the diaphragm. The spleen has to be unattached to the pancreas in order to visualize the whole spleen as well as the backside of the pancreas. While treating the spleen without having to do surgery works well in some situations, there are other situations in which the person will bleed to death with a splenic injury and it is important to recognize this possibility and use surgery when needed.
While evaluating the patient with a possible spleen injury, it should be noted that drivers and passengers located just behind the drivers are at a greater risk of injury due to their location in a car involved in a side crash on the driver’s side.
A history of past procedures needs to be taken because the spleen may have been removed for another reason prior to the trauma. It should be noted that some people might have a history of something wrong with them that predisposes them to injury to the spleen. The patient or relatives should be asked about the taking of aspirin or other anticoagulants that could predispose the client to extra bleeding if the spleen is ruptured.
On examination, tenderness to the ribs on the left side is important as this could indicate a fracture of the ribs and underlying spleen injury. About 14 percent of people with left sided rib tenderness will have a spleen injury. If there is no tenderness on the left side, it doesn’t mean a spleen injury is not present, especially if the patient is comatose or has an altered level of consciousness.
There can be localized tenderness to the left upper quadrant of the abdomen on examination. There may be bruising or abrasion to the area above the spleen. There are no blood tests for a spleen injury although a hemoglobin and blood typing should be done in case of blood loss.
A diagnostic peritoneal lavage in which fluid is instilled in the abdomen and allowed to sit for a while before removing it and looking for blood is less used these days to identify a spleen injury. A better test is an ultrasound of the spleen or a CT scan of the spleen. If a peritoneal lavage is done and no fluid comes back, it could mean that the left diaphragm has become ruptured and the fluid has been sucked up inside the chest cavity.
The ultrasound of the abdomen is a good screening test but does not mean that the spleen itself is ruptured. CT scanning is the best way of monitoring bleeding inside the spleen and is used regularly in the non-operative management of spleen injuries. IV contrast dye is often used to outline areas of bleeding.
On CT scanning, there can be free fluid seen around the spleen or throughout the abdomen. There can also be seen areas of less density that represent disruption of the spleen capsule or a blood clot in the area of the spleen. When the spleen is injured, there can be the obvious finding of dye-containing blood flowing out of the spleen itself. Remember that other areas near the spleen can be affected in trauma and injuries, especially to the kidney and pancreas, can be significant. MRI screening can be done of the spleen but it isn’t any better than a good CT scan of the area and is a slower procedure to do than the CT scan of the abdomen.
Grading Systems for Spleen Injuries
There are a number of different grading systems devised to decide how serious a spleen injury is. The best known grading system has been put out by the American Association for the Surgery of Trauma. It uses a scale from I to V to identify the severity of the injury. It should be noted that the CT scan of the spleen and the appearance of the spleen at the time of surgery. Usually, the CT scan underestimates the degree of injury to the spleen when compared to what it looks like in surgery.
The grading system looks like this:
- I—a small blood clot that is not getting any bigger
- II—a split in the capsule of the spleen
- III—a deep laceration into the bulk of the spleen
- IV—a large section of the spleen has no circulation because of an injured artery
- V—the spleen has been broken in half
Non-operative Management of a Spleen Injury
This has become more common over time. Sixty percent of spleen injuries can be treated this way. If the patient has a low blood pressure, this should be considered a worrisome sign and may lead to the decision to do surgery. If the patient is awake and can cooperate with an examination, the doctor should look for left upper quadrant abdominal pain. Pain that is all over the abdomen can mean that infection has spread throughout the abdomen and may confuse the picture. The most common CT finding in a splenic rupture is free fluid in the abdomen.
Non-operative management can only be done when the patient can be admitted and followed closely for changes in the examination or in the CT evaluation. If the CT scan shows a ruptured spleen and the patient is stable, it is reasonable to continue to watch the patient rather than do surgery to evaluate the spleen. If the hematocrit drops to a certain level, however, surgery is undertaken. Children tend to be better candidates for non-operative management because they have tougher spleens and would suffer greater infection problems should their spleen be removed.
Some patients can undergo angiography (a dye study of the arteries of the spleen) and can have the blood supply to the injured part of the spleen in order to stop the bleeding without having to do surgery. This is done in a highly selected group of patients with spleen injury in order to avoid surgery.
Patients who are selected to have non-operative treatment for their spleen injury should be admitted to the intensive care unit for monitoring. These people have regular hematocrit levels and regular abdominal examinations to see if there is any change over time. The patient should have nothing by mouth in case surgery turns out to be the option. The vital signs and urine output should be evaluated to assess the possibility of continued bleeding.
Vaccines should be given against streptococcal, meningococcal, and Hemophilus infections in case the patient eventually requires a spleen removal. The absence of the spleen makes the patient more likely to have infections by these organisms and the vaccines can prevent that.
The patient should be kept in the intensive care unit for up to 72 hours so that the stability of their spleen lesion can be determined. The patients can usually eat by this time as surgery is unlikely. Most failures of non-operative approaches to spleen surgery occur within the first 6-8 days after injury so, after that point, it is probably safe to allow the patient to be discharged from the hospital. This is especially the case if the patient lives close to the hospital and can return if things seem to be getting worse.
A repeat CT scan can be done after the patient has been discharged from the hospital. A usual time of repeat scanning is when the patient is scheduled to go back to contact sports. They shouldn’t be allowed to play contact sports until a CT clears them of having splenic bleeding or worsened injury. The typical recommendations are to avoid contact sports for 2-6 months after the injury.
A midline abdominal excision is the best choice for splenic injuries. Other intra-abdominal injuries can be assessed at the same time as the splenic injury. The surgeon looks for clots in the abdomen, which is usually the site of some bleeding or injury. The abdomen should be packed before any definitive surgery is done on the spleen or any other part of the abdominal organs. In some cases, as with multiple injuries to the abdomen, the spleen is removed first in order to stop the bleeding coming from the spleen which can interfere with the treatment of other injuries.
If the diaphragm is ruptured and the spleen has been pushed up into the chest cavity, it should be pulled out of the diaphragm hole in order to treat it on the abdominal side. The pancreas and kidney should be carefully looked at in such situations as they are attached to the spleen.
The spleen is often mobilized from all of its connections so that all sides of the spleen can be checked for injury. It is important to handle the spleen carefully so as not to worsen the injury to the spleen. The ligaments that hold the spleen must be disrupted in a specific order to better display the entire spleen.
What to do after the spleen has been freed of all its connections depends on the amount of injury to the spleen. If the spleen is not at all injured, it can be left in place. If it is injured in a minor way, the bleeding can be stopped using fibrin glue or gelatin sponges to stop the bleeding. The spleen can be sutured, but it doesn’t hold sutures very well.
Part of the spleen can be removed in moderate injuries. The surgeon cuts off the blood supply to the injured parts of the spleen and then removes that part of the spleen that now doesn’t have a blood supply. High grade injuries of the spleen necessitate removal of the spleen in its entirety. The part of the tissues left behind should be packed and later watched for bleeding that can subsequently be stopped.
The most common complication of non-operative management of a damaged kidney is the need for an operation later on. The surgeon can watch the hematocrit to see if there is continued bleeding and go to surgery when it reaches a specific low point. Another complication of non-operative management is the missed opportunity to find and treat other abdominal injuries.
Complications of doing an operation on the spleen include a risk of bleeding from blood vessels that have been disrupted but weren’t properly tied off during surgery. The pancreas can also be injured as part of the surgery to correct the spleen. Finally, there is a risk of infection after removal of the spleen but this should not be a reason to remove the spleen if it is hemorrhaging.