Summary![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
Injury to the spleen is most often the result of blunt abdominal trauma. In rare cases, it may also be caused by spontaneous rupture from an infection or a hematological condition. A ruptured spleen may result in massive intra-abdominal bleeding and should therefore be treated as a medical emergency. Rupture of the spleen may be acute or delayed: acute rupture, in which the patient immediately presents in severe pain and shock, is differentiated from a delayed rupture, which presents with sudden onset of pain and shock following a symptom-free interval lasting days to weeks. Depending on the severity of the injury, conservative therapy with observation in a high dependency unit may be considered, but most patients require surgical intervention. A splenic salvage maneuver (i.e., suturing, coagulation) is performed when possible; however, a splenectomy is commonly indicated in extensive injury involving the splenic hilum and may be a lifesaving procedure.
Etiology![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
Traumatic splenic rupture [1]
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Blunt abdominal trauma
- Most frequently caused by motor vehicle accidents
- Other settings of injury include contact sports, physical altercations, and falls from great heights
- Left-sided thoracic trauma with fractures of the lower ribs
- Penetrating abdominal trauma (e.g., stab wounds, gunshot wounds)
- Explosion-related blunt and/or penetrating trauma
Atraumatic splenic rupture [2]
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Severe splenomegaly due to, e.g.:
- Infection (e.g., malaria, mononucleosis, HIV)
- Leukemia (See “Clinical features” in “Acute leukemia” and “Chronic myeloid leukemia” for details.)
- Inflammation (e.g., pancreatitis)
- Medication related (e.g., anticoagulation)
- Accumulation (e.g., amyloid protein in amyloidosis or glycogen in glycogen storage disorders)
- Pregnancy [3]
- Congestion secondary to portal hypertension
- Iatrogenic (post-surgery or post-endoscopy)
Pathophysiology![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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Anatomy
- The spleen lies within the intraperitoneal cavity and is protected by the rib cage.
- Close proximity to: stomach (intraperitoneal), colon (transverse: intraperitoneal, descending: retroperitoneal), left kidney, pancreas (both retroperitoneal)
- Highly vascularized organ
- Lymphatic organ with filtering function
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Mechanisms of splenic rupture
- Acute rupture: injury of the splenic capsule and possibly the splenic parenchymal tissue → acute intra-abdominal bleeding
- Delayed rupture: injury of the splenic parenchymal tissue in an initially intact splenic capsule → central or subcapsular hematoma → asymptomatic interval (days to weeks) as hematoma distends inside the capsule → subsequent capsular rupture with intra-abdominal bleeding
Clinical features![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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Diffuse abdominal pain, especially in the left upper quadrant (LUQ), possible abdominal guarding
- Kehr's sign: referred pain in the left shoulder
- Ballance's sign: dullness on percussion in the LUQ
- Hemorrhagic shock (often delayed): tachycardia and hypotension
- In delayed splenic rupture, symptoms may not present until days to weeks after trauma
It is important to identify signs of any other major life-threatening injury in a polytrauma patient! (see blunt abdominal trauma for details)
Diagnostics![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
- Laboratory tests: low Hb, leukocytosis, and thrombocytosis ; crossmatch for blood transfusion if needed
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In hemodynamically unstable patients
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First ultrasound: focused assessment with sonography (FAST):
- Screening for central or subcapsular hematoma
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Free intra-abdominal fluid – preferred sites of collection:
- Koller pouch: splenorenal recess
- Morison pouch: hepatorenal recess
- Pouch of Douglas: between the rectum and, the bladder (in males) or uterus (in the females)
- If free intraabdominal fluid → diagnostic laparoscopy/laparotomy
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First ultrasound: focused assessment with sonography (FAST):
Repeated ultrasound examination is crucial, especially in conservative management of splenic rupture!
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In hemodynamically stable patients (or in unstable patients in which temporary stabilization with IV fluid resuscitation is successful)
- Method of choice: abdominal CT scan (with contrast)
- Alternative: MRI , angiography
- Sometimes: chest x-ray, abdominal x-ray
- Always consider other organs that could be injured (see “Differential diagnosis” below)
Differential diagnoses![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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Other injuries related to blunt abdominal trauma
- Liver injury (e.g., hematoma, rupture)
- Pancreatic injury (e.g., laceration, rupture)
- Duodenal damage and hematoma, especially in children
References:[4][5]
The differential diagnoses listed here are not exhaustive.
Treatment![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
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Hemodynamically stable patients [6][7][8]
- Conservative management (e.g., hospital observation with frequent ultrasound examination)
- Angiographic embolization of the injured blood vessel is becoming more widely used, particularly in stable patients.
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Hemodynamically unstable patients: laparotomy
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If hilar rupture: splenectomy
- If necessary, reimplantation of splenic tissue
- If only peripheral rupture: trial of splenic salvage – suturing, coagulation, or ligation of the injured blood vessel
- Alternative: partial splenic resection
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If hilar rupture: splenectomy
Splenectomy is a lifesaving procedure for hemodynamically unstable patients with continuous bleeding!
Complications![toggle arrow icon](https://manus-media.amboss.com/icons/chevron_up.svg)
Complications of splenic rupture
- Life-threatening hypovolemic and hemorrhagic shock
- Pancreatic injury (tail)
Complications of splenectomy
- Overwhelming post-splenectomy infection (OPSI): higher incidence of infection (see “Infection in asplenic patients” for details)
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Subphrenic abscess: an accumulation of pus located directly under the diaphragm [9]
- Epidemiology
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Etiology: polymicrobial infection (e.g., due to Enterococcus spp., E. coli, and Clostridium spp.) following intraperitoneal perforation
- Most commonly a complication of surgery (e.g., splenectomy, gastrectomy) or secondary to conditions such as diverticulitis, duodenal ulcers, and appendicitis
- Trauma
- Pathophysiology: See “Abscess” for details.
- Clinical features: most commonly develop 3–6 weeks after surgery
- Fever
- Pain over the 8th–11th ribs on the affected side
- Cough, increased respiratory rate, pleural effusion
- Diagnostics [10]
- CBC: leukocytosis
- Ultrasound can be used to visualize the abscess.
- Chest x-ray shows air below the diaphragm.
- Treatment: abscess drainage and antibiotic treatment (empiric, followed by tailored treatment according to antibiogram)
- Complications: empyema, sepsis
- Prognosis: high mortality (∼ 30%)
Overwhelming post-splenectomy infection is a potentially life-threatening complication.
We list the most important complications. The selection is not exhaustive.