Dr. Raheel Anis
INTRODUCTION

 Spleen is one of the most commonly injured intra-abdominal

organs

 In up to 60 percent of patients, the...
Anatomy
Anatomy
 Spleen lies in posterior portion of left upper quadrant, deep to

9, 10 and 11 ribs
 Convex surface lies under ...
 Situated

Posteriorly

left

upper

abdomen
 Covered by peritoneum except at the

hilum
 Posterior and lateral surface...
 Posteriorly

related to left
iliopsoas muscle & left adrenal
glands

 Posterior medial surface related

to body & tail ...
 Inferiorly

related to distal
transverse colon & splenic flexure

 Lower pole attached to colon

through splenicocolic ...
ARTERIAL SUPPLY
Receives blood supply from celiac axis
1.Spleenic artery

2.Short gastric vessels that connect left gastro...
VENOUS DRAINAGE
 Through splenic vein

 Joins superior mesenteric vein to form portal vein
PHYSIOLOGIC FUNCTIONS
A. Filtering – splenic blood flow – 350 ml/day
1. Removal of abnormal red blood cells approximately ...
MECHANISM OF INJURY
 Splenic injury most commonly occurs following blunt trauma

due to motor vehicle collisions
 Penetr...
HISTORY AND PHYSICAL EXAMINATION
 History of trauma,
 Left-upper quadrant, left rib cage, or left flank
 Negative histo...
SIGN & SYMPTOMS

 Complain of left upper abdominal, left chest wall, or left

shoulder pain (ie, Kehr's sign).
 (Kehr's ...
ON EXAMINATION
 Vitals are most important

 r/o left lower rib tenderness






14% patients with left lower rib
tend...
Diagnostic evaluation
 Focused assessment with sonography in trauma (FAST

exam),
 FAST exam is more useful in hemodynam...
SPECIFIC DIAGNOSTIC FINDINGS
 FAST findings
o

Signs of splenic injury observed with FAST examination
include a finding o...
 CT findings
 In non-injured patients


CT scan is typically performed with both oral (PO) and
intravenous (IV) contras...
CT scan findings that indicate splenic
injury include
 Hemoperitoneum – Localized fluid collections around the spleen

(e...
SPLENIC INJURY WITH EXTRAVASATION
OF CONTRAST
MINOR BLUNT SPLENIC INJURY
MODERATELY SEVERE BLUNT SPLENIC
INJURY
OTHER IMAGINGS
 Plain films, organ-based ultrasound imaging, and magnetic resonance

imaging (MRI) are of limited value i...
SPLENIC INJURY GRADING
 The AAST criteria for hematoma and laceration for each splenic injury grade are as
follows

Grade...
MANAGEMENT APPROACH
 Splenic injury can be initially managed with..
 Observation
 Angiographic embolization
 Surgery d...
HEMODYNAMICALLY UNSTABLE
Based upon ATLS principles, the hemodynamically
unstable trauma patient with a positive

FAST sca...
HEMODYNAMICALLY STABLE
Hemodynamically stable patients with
low-grade (I to III) blunt or penetrating splenic injuries

wi...
 CT scan findings of contrast extravasation or vascular blush

have higher failure rates for observational management
 P...
NONOPERATIVE MANAGEMENT
 Nonoperative management, encompassing both

observation and embolization techniques, is used to
...
Rationale for nonoperative management is based

upon the assumption that salvaging functional splenic
tissue avoids the su...
CONTRAINDICATIONS TO NONOPERATIVE
MANAGEMENT
 Nonoperative management is not appropriate in patients with
 Hemodynamic i...
RELATIVE CONTRAINDICATIONS
 Portal hypertension
 Higher-grade splenic injury (>Grade III),
 Active contrast extravasati...
 The optimal management of hemodynamically stable

patients with higher-grade (IV, V) injuries remains
controversial
 Th...
ONE SMALL RETROSPECTIVE REVIEW
 60 percent of patients with higher grade injuries were

taken directly to the operating r...
 Embolization is also relatively contraindicated in

patients older than 55 due to higher failure rates in
these patients...
OBSERVATION
 Successful

observation
during
non-operative
management for splenic trauma depends upon
 Proper patient sel...
 Initially place the patient on bed rest,

 Serial hemoglobin levels every six hours in the first

24 hours.
 NPO for a...
 Do not routinely perform repeat CT imaging during the

course of hospitalization
 Follow-up study is performed for pati...
Duration of observation should be individualized based upon
 the grade of splenic injury,
 nature
 severity of other in...
One multicenter trial found that
 86

percent of patients who failed nonoperative
management did so within 96 hours of ho...
FAILURE OF OBSERVATION
 require either splenic embolization, or more commonly, operative management
 "delayed splenic ru...
SPLENIC EMBOLIZATION
 Requires specialized imaging facilities and a vascular interventionalist
 Potentially most useful ...
FOLLOW-UP CARE
 Resumption of normal activities
 restricted from participation in high-risk activities up to

three mont...
OPERATIVE MANAGEMENT
 Splenic salvage or splenectomy
 sustaining abdominal trauma who are hemodynamically

unstable
 no...
SUMMARY AND RECOMMENDATIONS
Splenic injury can result from either blunt or penetrating chest or
abdominal trauma; blunt m...
clinical history and physical examination are not sufficiently sensitive or
specific for the presence of splenic injury
...
 Hemodynamically stable patients with low grade (I to III) injuries, we suggest
nonoperative management over definitive s...
For patients who develop hemodynamic instability during the course of
nonoperative management, we suggest surgical explor...
THANK YOU
Conservative management of spleenic injury by dr. raheel anis.
Conservative management of spleenic injury by dr. raheel anis.
Conservative management of spleenic injury by dr. raheel anis.
Conservative management of spleenic injury by dr. raheel anis.
Conservative management of spleenic injury by dr. raheel anis.
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Conservative management of spleenic injury by dr. raheel anis.

  1. 1. Dr. Raheel Anis
  2. 2. INTRODUCTION  Spleen is one of the most commonly injured intra-abdominal organs  In up to 60 percent of patients, the spleen is the only organ injured  Diagnosis and prompt management of potentially life- threatening hemorrhage is the primary goal  Any attempt to salvage the spleen is abandoned in the face of ongoing hemorrhage or other life-threatening injuries  Emergent and urgent splenectomy remains a life-saving measure for many patients
  3. 3. Anatomy
  4. 4. Anatomy  Spleen lies in posterior portion of left upper quadrant, deep to 9, 10 and 11 ribs  Convex surface lies under lt hemidiaphargm  Concavities on medial side due to impression by neighbouring structures  Average length 7-11cm  Weight 150 grams (70-250)  Tail of pancreas lies incontact with spleen in 30% and within 1cm in 70%
  5. 5.  Situated Posteriorly left upper abdomen  Covered by peritoneum except at the hilum  Posterior and lateral surface related to left hemidiaphragm posterolateral lower ribs and  Lateral surface attached through splenophrenic ligament
  6. 6.  Posteriorly related to left iliopsoas muscle & left adrenal glands  Posterior medial surface related to body & tail of pancreas  Anteriomedially related to great curvature of stomach
  7. 7.  Inferiorly related to distal transverse colon & splenic flexure  Lower pole attached to colon through splenicocolic ligament  These attachments require devision during mobilisation
  8. 8. ARTERIAL SUPPLY Receives blood supply from celiac axis 1.Spleenic artery 2.Short gastric vessels that connect left gastroepiploic artery. & splenic circulation along greater curvature of stomach
  9. 9. VENOUS DRAINAGE  Through splenic vein  Joins superior mesenteric vein to form portal vein
  10. 10. PHYSIOLOGIC FUNCTIONS A. Filtering – splenic blood flow – 350 ml/day 1. Removal of abnormal red blood cells approximately 20 ml of aged RBC are removed daily 2.Removal of abnormal WBC , Plateletes B. Immunologic Function 1. Opsonin production 2. Antibody synthesis (IgM) 3. Protection from infection C. Storage Function 1. Plateletes – 1/3 are stored in the spleen 2. In splenomegaly, up to 80% of the plateletes may be stored in the spleen  thrombocytopenia
  11. 11. MECHANISM OF INJURY  Splenic injury most commonly occurs following blunt trauma due to motor vehicle collisions  Penetrating splenic trauma is less common than blunt injury  Iatrogenic traumatic injuries to the spleen can result from surgical or endoscopic manipulation  colon,  stomach,  pancreas,  Kidney  primary mechanism is capsular tear, laceration from retraction devices, or tension on the spleen during manipulation of the colon
  12. 12. HISTORY AND PHYSICAL EXAMINATION  History of trauma,  Left-upper quadrant, left rib cage, or left flank  Negative history does not reliably exclude splenic injury  Penetrating object can injure the spleen even if the entrance wound is not in proximity to the spleen
  13. 13. SIGN & SYMPTOMS  Complain of left upper abdominal, left chest wall, or left shoulder pain (ie, Kehr's sign).  (Kehr's sign) is pain referred to the left shoulder that worsens with inspiration and is due to irritation of the phrenic nerve from blood adjacent to the left hemidiaphragm  Abdominal tenderness and peritoneal signs  Abdominal wall contusion or hematoma (eg, seat belt sign),  Associated injuries  With blunt abdominal trauma, lower rib fractures, pelvic fracture, and spinal cord injury may also be present
  14. 14. ON EXAMINATION  Vitals are most important  r/o left lower rib tenderness    14% patients with left lower rib tenderness have splenic injury In children plasticity of chest will have splenic injury without rib # Ecchymoses or abration over LUQ
  15. 15. Diagnostic evaluation  Focused assessment with sonography in trauma (FAST exam),  FAST exam is more useful in hemodynamically unstable patients  Computerized tomography (CT scan).  Diagnostic peritoneal aspiration/lavage (DPA/DPL) is less common
  16. 16. SPECIFIC DIAGNOSTIC FINDINGS  FAST findings o Signs of splenic injury observed with FAST examination include a finding of hypoechoic (ie, black) rim of subcapsular fluid or intraperitoneal fluid usually found around the spleen or in Morrison’s pouch (hepatorenal space).
  17. 17.  CT findings  In non-injured patients  CT scan is typically performed with both oral (PO) and intravenous (IV) contrast  For obvious reasons, non-intravenous contrast CT scan cannot establish the presence of active bleeding (ie, contrast blush, active extravasation).
  18. 18. CT scan findings that indicate splenic injury include  Hemoperitoneum – Localized fluid collections around the spleen (especially those with an elevated Hounsfield unit measurement) are highly suggestive of hemoperitoneum. Briskly bleeding splenic lacerations may establish blood density fluid throughout the abdomen.  Hypodensity – Hypodense regions represent areas of parenchymal disruption, intraparenchymal hematoma or subcapsular hematoma.  Contrast blush or extravasation – Contrast blush describes hyperdense areas within the splenic parenchyma that represent traumatic disruption or pseudoaneurysm of the splenic vasculature. Active extravasation of contrast implies ongoing bleeding and the need for urgent intervention
  19. 19. SPLENIC INJURY WITH EXTRAVASATION OF CONTRAST
  20. 20. MINOR BLUNT SPLENIC INJURY
  21. 21. MODERATELY SEVERE BLUNT SPLENIC INJURY
  22. 22. OTHER IMAGINGS  Plain films, organ-based ultrasound imaging, and magnetic resonance imaging (MRI) are of limited value in the acute diagnosis of splenic injury  Plain films are generally nonspecific but may demonstrate rib fracture, or medial displacement of the gastric air bubble (ie, Balance sign) raising suspicion for a splenic injury.  MRI and organ-based ultrasound examination may be time-consuming to perform, and may put the patient in a location of the hospital remote from ready access and intervention. However, MRI may be applicable in a subset of hemodynamically stable patients who cannot undergo CT scan (eg, allergic to IV contrast)
  23. 23. SPLENIC INJURY GRADING  The AAST criteria for hematoma and laceration for each splenic injury grade are as follows Grade I — Hematoma: subcapsular, <10 percent of surface area. Laceration: capsular tear <1 cm in depth into the parenchyma Grade II — Hematoma: subcapsular, 10 to 50 percent of surface area. Laceration: capsular tear, 1 to 3 cm in depth, but not involving a trabecular vessel. Grade III — Hematoma: subcapsular, >50 percent of surface area OR expanding, ruptured subcapsular or parenchymal hematoma OR intraparenchymal hematoma >5 cm or expanding. Laceration: >3 cm in depth or involving a trabecular vessel. Grade IV — Laceration involving segmental or hilar vessels with major devascularization (ie, >25 percent of spleen) Grade V — Hematoma: shattered spleen. Laceration: hilar vascular injury which devascularizes spleen.
  24. 24. MANAGEMENT APPROACH  Splenic injury can be initially managed with..  Observation  Angiographic embolization  Surgery depending upon the hemodynamic status  Grade of splenic injury  Presence of other injuries and medical comorbidities.
  25. 25. HEMODYNAMICALLY UNSTABLE Based upon ATLS principles, the hemodynamically unstable trauma patient with a positive FAST scan or DPA/DPL requires emergent abdominal exploration to determine the source of intraperitoneal hemorrhage
  26. 26. HEMODYNAMICALLY STABLE Hemodynamically stable patients with low-grade (I to III) blunt or penetrating splenic injuries without any evidence for other intra-abdominal injuries, active contrast extravasation, or a blush on CT, may be initially observed safely.
  27. 27.  CT scan findings of contrast extravasation or vascular blush have higher failure rates for observational management  Patients may benefit from initial splenic embolization followed by continued observation  Another indication for embolization is intraparenchymal pseudoaneurysm formation  Splenic embolization is controversial for higher grade (IV, V) injuries and in patients older than 55
  28. 28. NONOPERATIVE MANAGEMENT  Nonoperative management, encompassing both observation and embolization techniques, is used to manage 50 to 70 percent of cases  Typically for patients with lower grade injuries
  29. 29. Rationale for nonoperative management is based upon the assumption that salvaging functional splenic tissue avoids the surgical and anesthetic risks and complications associated with laparotomy and abrogates the risk of postsplenectomy sepsis.
  30. 30. CONTRAINDICATIONS TO NONOPERATIVE MANAGEMENT  Nonoperative management is not appropriate in patients with  Hemodynamic instability,  Generalized peritonitis,  Other intra-abdominal injuries requiring surgical exploration  Portal hypertension is a relative contraindication  Higher-grade splenic injury (>Grade III), J
  31. 31. RELATIVE CONTRAINDICATIONS  Portal hypertension  Higher-grade splenic injury (>Grade III),  Active contrast extravasation  Large volume hemoperitoneum (though difficult to accurately quantify),  Refusal of blood transfusion  Altered neurologic status precluding adequate serial abdominal examination
  32. 32.  The optimal management of hemodynamically stable patients with higher-grade (IV, V) injuries remains controversial  Though grade V injuries are generally unsuitable for embolization due to vascular disruption  Grade IV injuries to be a relative contraindication to splenic embolization
  33. 33. ONE SMALL RETROSPECTIVE REVIEW  60 percent of patients with higher grade injuries were taken directly to the operating room  remaining patients were managed nonoperatively with 55 percent of these patients ultimately requiring surgery  prefer to initially manage hemodynamically stable patients with Grade III or IV splenic injury with angiographic embolization as part of their nonoperative management, provided that they do not have large volume hemoperitoneum or other injuries that require abdominal exploration or medical comorbidities providing a contraindication.
  34. 34.  Embolization is also relatively contraindicated in patients older than 55 due to higher failure rates in these patients  Retrospective reviews suggest, however, that carefully selected individuals over 55 who are hemodynamically stable, and have no significant medical comorbidities, can also be safely managed with observation, with or without embolization
  35. 35. OBSERVATION  Successful observation during non-operative management for splenic trauma depends upon  Proper patient selection  Availability of adequate resources  Closely monitored by nursing and medical staff
  36. 36.  Initially place the patient on bed rest,  Serial hemoglobin levels every six hours in the first 24 hours.  NPO for at least the first 24 hours.  When the hemoglobin level is stable and operative intervention unlikely, the patient may eat.
  37. 37.  Do not routinely perform repeat CT imaging during the course of hospitalization  Follow-up study is performed for patients whose clinical situation (ie, falling hemoglobin, increasing abdominal pain, left shoulder pain, fever) indicates a need.  With higher grade injuries (III to V), a repeat scan within 24 to 48 hours may be needed if the clinical situation is unclear
  38. 38. Duration of observation should be individualized based upon  the grade of splenic injury,  nature  severity of other injuries  patient's clinical status  higher-grade injury generally required longer observation periods  duration of observation following splenic injury is that the number of days of observation is equal to the injury grade plus one
  39. 39. One multicenter trial found that  86 percent of patients who failed nonoperative management did so within 96 hours of hospital admission,  with 61 percent of failures occurring during the first 24 hours
  40. 40. FAILURE OF OBSERVATION  require either splenic embolization, or more commonly, operative management  "delayed splenic rupture". more accurately describes those patients with splenic parenchymal pseudoaneurysms  hemodynamic instability  the development of diffuse peritoneal signs  decreasing hemoglobin attributed to splenic hemorrhage.  Hypotension may be absolute or relative, or evidenced as persistent tachycardia in spite of adequate fluid resuscitation.
  41. 41. SPLENIC EMBOLIZATION  Requires specialized imaging facilities and a vascular interventionalist  Potentially most useful when employed selectively in hemodynamically stable patients who have CT findings that include active contrast extravasation, splenic pseudoaneurysm, or large volume hemoperitoneum  Retrospective reviews have found variable success rates (57 to 93 percent) for splenic salvage that includes embolization in patients with higher-grade (III, IV, V) splenic injuries  Retrospective studies have demonstrated that nonoperative management is more successful with the adjunctive use of angio-embolization
  42. 42. FOLLOW-UP CARE  Resumption of normal activities  restricted from participation in high-risk activities up to three months  retrospective review, healing was demonstrated radiographically within two months of injury in 80 percent of patients; however, grade V injuries were excluded in this  Imaging studies  not routinely perform repeat CT imaging
  43. 43. OPERATIVE MANAGEMENT  Splenic salvage or splenectomy  sustaining abdominal trauma who are hemodynamically unstable  not candidates for nonoperative management  those who fail nonoperative management strategies require
  44. 44. SUMMARY AND RECOMMENDATIONS Splenic injury can result from either blunt or penetrating chest or abdominal trauma; blunt mechanisms are more common Splenic injury can also be due to iatrogenic injury Perform initial resuscitation, diagnostic evaluation, and management of the trauma patient based upon protocols from the Advanced Trauma Life Support A suspicion for splenic injury is increased with left upper quadrant and/or left chest trauma
  45. 45. clinical history and physical examination are not sufficiently sensitive or specific for the presence of splenic injury Findings indicative of splenic injury on focused assessment with sonography for trauma (FAST) CT scan) findings consistent with splenic injury …hypodensity, intraparenchymal or subcapsular hematoma, intravenous contrast blush, active intravenous contrast extravasation or hemoperitoneum
  46. 46.  Hemodynamically stable patients with low grade (I to III) injuries, we suggest nonoperative management over definitive surgical intervention Failure of nonoperative management indicates a need for angiographic embolization, if not initially used, or surgical exploration
  47. 47. For patients who develop hemodynamic instability during the course of nonoperative management, we suggest surgical exploration over splenic embolization Asplenic patients are regarded as having impaired immunity to encapsulated organisms and should be immunized against encapsulated organisms
  48. 48. THANK YOU

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