B9. Traumatic and spontaneous rupture of the spleen
Rupture of the spleen is a potentially life-threatening condition. The spleen has a rich blood supply and rupture may therefore cause severe haemorrhage, haemorrhagic shock, or death.
It’s the most frequent organ injury after blunt abdominal trauma cases, in which it occurs in 25% of cases.
The spleen may rupture into an intact splenic capsule, in which case the bleeding will be contained for days or weeks until the capsule ruptures, causing haemorrhagic instability much later than the injury.
Etiology
- Traumatic splenic rupture
- Blunt abdominal trauma (most common cause)
- Fracture of lower left ribs
- Penetrating abdominal trauma
- Atraumatic splenic rupture
- Spontaneous rupture due to severe splenomegaly
- Mononucleosis
- Malaria
- Leukaemia
- Cysts or abscesses
- Iatrogenic
- Colonoscopy
- Surgery
- Spontaneous rupture due to severe splenomegaly
Clinical features
Splenic rupture may cause severe intraabdominal haemorrhage, which may manifest as anaemia, haemodynamic instability, or shock. There may be abdominal pain with peritonitis, either diffuse or localised to the left upper quadrant. There may be symptoms of other injuries from the trauma, like rib fracture pain and shoulder pain. Due to the mechanism described above, haemorrhage may occur days or weeks after the trauma.
Diagnosis and evaluation
Patients who have experienced major trauma are usually examined with ultrasound as part of eFAST. If positive, the patient will be taken to surgery. CT may also be used to show the injury. On ultrasonography, blood is hypodense.
Treatment
Treatment is mostly surgical, either with laparoscopy or open surgery (laparotomy). Splenic surgery may cause severe intraoperative haemorrhage so it’s important to be prepared for this. Mild injuries may be treated conservatively with close follow-up.
There are many options to treating splenic rupture, depending on the extent of the injury:
- Angiographic embolization of the injured blood vessel
- Using modern haemostatic preparations
- Suture, coagulation, or ligation of the injured blood vessel
- Partial splenic resection
- Splenectomy
After splenectomy, we can auto-transplant slices of the spleen into the omentum of the patient. This may reduce the complications of asplenism (loss of spleen function). Vaccination against encapsulated bacteria in patients receiving a splenectomy is important to prevent overwhelming post-splenectomy infection.