Splenic Rupture

Question 1

Why are splenic ruptures important to consider?

Answer 1

The spleen is extremely vascular

Splenic rupture can lead to large intraperitoneal haemorrhage and rapidly cause fatal haemorrhagic shock

Question 2

Majority of cases of splenic injury is due to what?

Answer 2

Secondary to abdominal trauma, especially if it blunt trauma.

E.g. seat-belt injuries in RTC and falls onto the side.

Question 3

Rares causes of splenic rupture

Answer 3

Iatrogenic

Splenomegaly from haematological malignancy or infective causes like EBV.

When the spleen grows the capsule stretches and thins so it becomes more fragile

Question 4

Clinical features

Answer 4

Hx of trauma usually

Abdo pain + hypovolaemic shock

Question 5

Examination findings

Answer 5

LUQ tenderness

Peritonism

Free blood can also irritate the diaphragm causing radiationg left shoulder pain AKA Kehr’s sign

Question 6

Investigations if haemodynamically unstable.

Answer 6

Haemodynamically unstable patients with peritonism following trauma have abdo bleeding until proven otherwise.

This requires immediate laparotomy

Question 7

Investigations in haemodynamically stable patients with suspected abdominal injury.

Answer 7

Urgent CT chest-abdo-pelvis with IV contrast

Question 8

Imaging findings

Answer 8

Identification and assessment of splenic injury + any other abdo viscera involved.

Also allows for the grading of the splenic injury to guide management

Question 9

What scale is used to grade splenic trauma?

Answer 9

American Association for the Surgery of Trauma (AAST) is a splenic injury scale.

Question 10

Explain AAST splenic injury scale

Answer 10

Used to help guide which patients are likely to benefit from conservative management and which need surgery

Question 11

Break down the AAST splenic injury scale

Answer 11

1 - Capsular tear <1cm parenchymal depth and subcapsular haematoma <10% surface area

2 - Capsular tear 1-3 cm parenchymal depth and subcapsular haematoma 10%-50% surface area or intraparenchymal <5cm

3 - Capsular tear >3 cm parenchymal depth or any tear involving trabecular vessels and subcapsular haematoma >50% surface area or intraparenchymal >5cm or expanding/ruptured haematoma

4 - Laceration involving segmental or hilar vessels devascularising >25% of spleen

5 - Completely shattered spleen or hilar vascular injury that devascularises the spleen.

Question 12

General management

Answer 12

All patients with suspected splenic injury should be assessed, resus and treated according to ATLS.

Question 13

Management of haemodynamically unstable or grade 5 injury

Answer 13

Urgent laparotomy (that includes splenectomy)

Question 14

Management of haemodynamically stable with grade 1-3 injuries

Answer 14

Conservative treatment

Resus should be done, placed on strict bed rest and have repeat CT scan at 1 week post injury

Question 15

What should be done if there is increasing tenderness or peritonitis?

Answer 15

Re-imaging and/or laparotomy

Question 16

What should all patients be given that are treated conservatively?

Answer 16

Prophylactic vaccination (against Strep Pneumoniae, Haemophilus Influenzae B (HIB) and Meningococcus) at discharge.

Question 17

When is embolisation done in splenic injury?

Answer 17

Vascular abnormalities or higher-grade splenic injuries may benefit.

This requires to be able to see the bleeding point however.

Even if embolisation is successful some will require splenectomy regardless.

Question 18

Complications of treatment

Answer 18

Ongoing bleeding

Splenic necrosis

Splenic abscess or cyst formation

Thrombocytosis

Question 19

Post-op management of splenectomy

Answer 19

Vaccinations for encapsulated bacteria

Abx prophylaxis (Penicillin V)