Splenic injuries

Splenic injuries range from small lacerations and hematomas to ruptures with significant tissue damage, vascular compromise, and life-threatening bleeding. They are most commonly caused by blunt abdominal trauma, but atraumatic injuries can also result from spontaneous rupture and infarctions due to underlying conditions such as infections or hematological abnormalities. A ruptured spleen can cause significant intraabdominal bleeding and should be treated as a medical emergency. Ruptures may be acute, with sudden onset of severe pain and shock, or may develop gradually (delayed splenic rupture). Minor lacerations, hematomas, and infarctions usually manifest with mild clinical features or only appear on imaging. Treatment depends on injury severity and hemodynamic status. Conservative therapy with observation may suffice for minor injuries, but some patients require angioembolization or surgery. Surgical interventions include splenic salvage procedures, if feasible, or a splenectomy for extensive injuries. Underlying conditions that contribute to atraumatic splenic injury may require additional management, e.g., treatment of infections or malignancies causing splenomegaly, or thromboembolic diseases causing splenic infarction.

Traumatic injuries ^[1][2]

• Major trauma ^[3]
  • Blunt abdominal trauma
    • Motor vehicle collisions (most frequent)
    • Contact sports
    • Physical altercations
    • Falls from height
  • Left-sided blunt thoracic trauma with lower rib fractures
  • Penetrating abdominal trauma (e.g., stab wounds, gunshot wounds to the left upper quadrant)
  • Blast injuries
• Iatrogenic trauma: postsurgery or postendoscopy
• Minor trauma: can cause splenic injuries in patients with severe splenomegaly ^[4]

Atraumatic injuries ^[5][6]

• Atraumatic splenic rupture is rare but can occur spontaneously if there is an underlying pathology, e.g.: ^[2][4][7]
  • Splenomegaly (see “Causes of splenomegaly” for underlying causes)
  • Other structural splenic abnormalities, e.g., cysts, hemangiomas
  • Inflammatory tissue damage (e.g., adjacent pancreatitis)
  • Coagulopathy
• Splenic infarction: may occur in patients with thromboembolic and vasocclusive diseases

Spontaneous splenic rupture can result from splenomegaly due to infectious diseases (e.g., mononucleosis, endocarditis, malaria), neoplasms (e.g., acute leukemia, lymphoma), and conditions that alter splenic circulation (e.g., sickle cell disease, portal hypertension, and pregnancy). ^[5][7]

Management is guided by hemodynamic stability rather than anatomic injury grading. Higher injury grades are often associated with hemodynamic instability. ^[8][9]

By anatomic grading of splenic injury ^[9][10]

This grading system is consistent with the American Association for the Surgery of Trauma (AAST) Organ Injury Scale, which is based on CT or intraoperative appearance of traumatic splenic injuries.

• Grade I: small subcapsular hematoma or capsular laceration
• Grade II: small to medium subcapsular or intraparenchymal hematoma, or superficial parenchymal laceration
• Grade III: large or ruptured hematoma and/or deep parenchymal laceration
• Grade IV: fragmented spleen and major vascular injury with significant splenic infarction
• Grade V: shattered spleen and hilar vascular injury with extensive splenic infarction

By overall clinical severity ^[8]

This system is consistent with the World Society of Emergency Surgery (WSES) classification of splenic trauma, which combines injury grade (based on the AAST Organ Injury Scale) and hemodynamic stability to determine overall clinical severity.

Mild (WSES class I)

• Hemodynamically stable or stabilized after immediate hemodynamic support
• Low AAST grade, i.e., I–II

Moderate (WSES class II–III)

• Hemodynamically stable or stabilized after immediate hemodynamic support
• Medium to high AAST grade
  • Grade III (WSES class II)
  • Grades IV–V (WSES class III)

Severe (WSES class IV)

• Hemodynamically unstable
• Any AAST grade, i.e., I–V

Management (operative vs. nonoperative) depends on hemodynamic stability at presentation and after initial resuscitation, splenic injury severity, associated injuries, and available resources.

Traumatic splenic injuries ^[3][11]

Use the ABCDE approach for all patients, and manage blunt abdominal trauma or penetrating abdominal trauma as needed. Blunt splenic injuries can be managed operatively or nonoperatively.

Hemodynamically unstable patients ^[8]

• Acute stabilization: Begin management of hemorrhagic shock and hemodynamic monitoring.
• Diagnostics ^[12]
  • Focused assessment with sonography for trauma (FAST exam): preferred initial study
  • If there is free intraabdominal fluid, proceed to exploratory laparotomy.
  • Laboratory tests for trauma
• Treatment
  • Laparotomy: can include splenic repair and partial or total splenectomy
  • Angioembolization ^[13][14]
    • Indications include active bleeding on imaging, injury grade ≥ III, vascular injury, pseudoaneurysm, AV fistula, and hemoperitoneum.
    • Optimal timing varies depending on patient stability and degree of blood loss.

Splenectomy is a lifesaving procedure for hemodynamically unstable patients with continuous bleeding!

Hemodynamically stable patients ^[8]

The following applies to patients who are stable at presentation or after initial resuscitation.

• Diagnostics
  • Gold standard imaging: abdominal CT scan with IV contrast
  • Alternative imaging: FAST, MRI
  • Additional diagnostics for trauma as needed
  • Serial laboratory studies (e.g., hemoglobin)
• Management ^[8][11][15]
  • Nonoperative management (NOM): preferred for hemodynamically stable patients with blunt splenic injuries regardless of grade ^[11]
    • Serial abdominal examination, including repeat FAST exam
    • Serial hemoglobin and hematocrit (serial H&H)
    • Acute pain management
  • Signs of clinical deterioration include:
    • New hemodynamic instability
    • New peritoneal signs
    • Intraperitoneal fluid on serial FAST exam
    • Drop in serial H&H
  • Consider angioembolization if there is clinical deterioration or ongoing bleeding on initial imaging. ^[13][14]
  • Surgery is indicated for clinical deterioration, no improvement with NOM, or for certain penetrating splenic injuries. ^[8][16]

Repeat ultrasound examinations to monitor for ongoing bleeding during nonoperative management of splenic rupture.

Atraumatic splenic injuries

• Atraumatic splenic rupture ^[5]
  • Management resembles approach for traumatic splenic injuries and requires surgical consultation. ^{[17][18][19][20]}
    • Most are treated operatively with splenectomy. ^[18]
    • Nonoperative management with adjunctive angioembolization can be considered in select cases.
  • Include workup and management of underlying causes of splenomegaly.
  • See “Management” in “Splenic rupture” for details.
• Spontaneous splenic infarctions ^[21][22][23]
  • Usually nonoperative management if there are no complications
  • Management of underlying causes, e.g., treatment of hypercoagulable states
  • See “Management” in “Splenic infarction” for details.

Description

• Splenic rupture is an injury that compromises the structural integrity of the splenic capsule, parenchyma, or vasculature.
• Although the term rupture can technically apply to any splenic injury (see “Classification”), it is most often used in clinical practice to describe severe and/or spontaneous injuries, e.g., atraumatic splenic rupture. ^[20]

Pathophysiology

• Acute splenic rupture: injury of the splenic capsule and possibly the splenic parenchymal tissue → acute intraabdominal bleeding
• Delayed splenic rupture: can occur if capsule ruptures days to weeks after subcapsular hematoma formation ^[12]

Etiology ^[3][4]

• Major trauma
• Minor trauma or spontaneous rupture: in patients with severe splenomegaly
• See “Etiology of splenic injuries” for details.

In delayed splenic rupture, symptoms may take days to weeks to manifest after abdominal trauma. ^[24][25]

Clinical features of splenic rupture ^[25]

• Diffuse abdominal pain, especially in the left upper quadrant (LUQ); possible abdominal guarding
  • Kehr sign: referred pain in the left shoulder
  • Ballance sign: dullness to percussion of the LUQ
• Hemorrhagic shock (often delayed): tachycardia and hypotension

Identifying signs of other critical injuries is crucial in patients with polytrauma (see “Blunt abdominal trauma” for details).

Diagnostics ^[8][12]

• FAST exam: Intraperitoneal hemorrhage or free fluid in the LUQ may be visible.
• CT abdomen with IV contrast: obtained once the patient is hemodynamically stable
  • Presence of a subcapsular hematoma ^[26]
  • Contrast blush may be observed on arterial and delayed phases signaling active hemorrhage. ^[12][27]
  • Perisplenic hematoma, hemoperitoneum

Management ^[8]

See “General management of splenic injuries” for details on the initial approach. Management of atraumatic splenic rupture closely resembles that of traumatic rupture. ^{[17][18][19][20]}

• Nonoperative management
  • Appropriate for hemodynamically stable patients with small, contained rupture without radiological signs of active bleeding (e.g., contrast blush)
  • May be appropriate for select patients with atraumatic splenic rupture ^[5]
  • Serial monitoring for signs of bleeding or complications
• Angioembolization
  • May be considered in patients with moderate to severe lesions or vascular injuries identified on CT (e.g., contrast blush, pseudoaneurysms, or AV fistulas)
  • Splenic artery angioembolization improves the success rate of nonoperative management. ^[28][29]
• Surgical management
  • Splenectomy for severe or ongoing bleeding, or if nonoperative management fails
  • Splenorrhaphy in select patients to preserve splenic function
  • Most patients with atraumatic splenic rupture require splenectomy. ^[5][18]
• After stabilization: Treat underlying causes of splenomegaly if present.

Blunt abdominal trauma can cause other visceral injuries (e.g., liver or pancreatic injury, duodenal hematoma), especially in children due to their thin abdominal walls.

Complications

• Life-threatening hypovolemic and hemorrhagic shock
• Pancreatic injury
• Complications of splenectomy, e.g., overwhelming postsplenectomy infection, subphrenic abscess

Description

• Splenic hematoma: accumulation of blood within the spleen that can vary in size and severity
• Minor laceration: small, superficial tear that rarely results in significant bleeding
• Major laceration: tear that extends deep into parenchyma and results in life-threatening intraabdominal hemorrhage

Pathophysiology

• Injury of the splenic parenchymal tissue in an initially intact splenic capsule → central or subcapsular hematoma → possible delayed splenic rupture
• Superficial tears or cuts in spleen tissue typically cause minimal to no bleeding.

Clinical features

• Minimal symptoms or asymptomatic
• Nonspecific abdominal pain
• Mild tenderness to palpation

Management ^[4][8]

See “General management of splenic injuries” for details on the initial approach.

• Minor splenic injuries are often discovered on imaging for other abdominal injuries or unexplained abdominal pain.
• Nonoperative management is appropriate for most stable patients.
• Angioembolization may be considered in patients who respond to fluid resuscitation if there is concern for ongoing bleeding (e.g., contrast blush on CT, decreasing hemoglobin). ^[30]
• Unstable patients may require urgent laparotomy with possible splenectomy.

Complications

• Delayed splenic rupture
• Splenic fragility (e.g., susceptibility to reinjury with low energy trauma)

Description

An ischemic injury to the spleen due to occlusion or disruption of the splenic artery.

Pathophysiology ^[31]

• Obstruction or disruption of the splenic artery or its branches → splenic infarction
• Ischemic injury to the spleen that results in tissue necrosis

Etiology ^[31][32]

• Traumatic: injury to the splenic vasculature (see “Etiology of splenic injuries” for details)
• Nontraumatic
  • Hypercoagulable states, e.g., cancer, antiphospholipid syndrome
  • Hematologic disorders, e.g., sickle cell disease
  • Thromboembolism, e.g., due to atrial fibrillation
  • Septic embolism, e.g., due to infective endocarditis
  • Iatrogenic, e.g., angioembolization

Clinical features ^[23][32]

• Sometimes asymptomatic
• Fever
• LUQ pain, referred left shoulder pain (Kehr sign)
• Nausea and vomiting
• Splenomegaly

Diagnostics ^[12]

• Laboratory studies: nonspecific findings (e.g., leukocytosis, increased LDH) ^[21]
• Imaging: CT scan typically shows nonenhancing, subcapsular, wedge-shaped lesions.

Management ^[21][22][23]

The following applies to nontraumatic splenic infarctions. Management of traumatic infarctions depends on hemodynamic stability, grade of vascular injury, and associated injuries (see “General management of splenic injuries”).

• Splenic infarctions are typically managed nonoperatively. ^{[22][33][34][35]}
• Surgery (e.g., splenectomy) is generally reserved for complications (e.g., postinfarction rupture, hemodynamic instability, abscess). ^[36][37]
• Provide supportive care, e.g., hydration and pain management.
• Identify and treat the underlying cause, e.g.:
  • Thrombophilia testing and treatment of hypercoagulable states
  • Afib diagnostics and anticoagulation for Afib
  • IE workup and management of IE
  • Screening for sickle cell disease and management of vasoocclusive crises

Complications ^[23]

• Hemorrhage
• Atraumatic splenic rupture
• Splenic abscess
• Pseudocyst
• Posttraumatic aneurysm ^[38]