2. • The spleen can rupture as—Trauma to a
normal spleen OR to a diseased spleen
• Atraumatic rupture of a diseased spleen
[pathologic (occult) rupture] and Spontaneous
rupture of a normal spleen [spontaneous
(idiopathic) rupture].
3. Causes
• Splenic injury occurs commonly following road traffic
accidents, other blunt injury or penetrating/stab injuries.
• Most often associated with fracture of left lower ribs,
haemothorax, injury of liver (left lobe commonly,
occasionally both lobes), bowel, tail of pancreas, left
kidney.
• Injury is more common and severe in enlarged spleen,
i.e. in malaria, tropical splenomegaly, infectious
mononucleosis.
• Spontaneous rupture of spleen can occur in malaria
and infectious mononucleosis.
• Spleen is the most common solid organ injured in blunt
abdominal trauma.
4. 1. Splenic subcapsular haematoma: After initial
injury patient remains asymptomatic for a
short period.
2. But this haematoma ruptures later, may be
after few days causing torrential
haemorrhage.
5. 2.Clean incised wound over the surface: This can be
treated by splenorrhaphy.
3. Lacerated wound.
4. Splenic hilar injury causes torrential
haemorrhage, may even cause death. So immediate
surgical intervention and splenectomy is done.
5. Splenic injury associated with other injuries (left
kidney, left colon, small bowel, pancreas,
diaphragm, left lung).
7. • Hilar injury presents with rapid development of shock
and deteriorates fast.
• Even death can occur sometimes. Here emergency
surgery and splenectomy is mandatory.
• In other types, features of shock (pallor, tachycardia,
restlessness, hypotension), pain, tenderness and
abdominal rigidity in left upper quadrant is seen.
• Later there will be abdominal distension due to
haemoperitoneum.
• Dullness in the left flank which does not shift, as the
collected blood gets clotted.
• Dullness without shifting— Ballance’s sign.
8. • Clot collected under the left side of the diaphragm irritates
it and the phrenic nerve causing referred pain in the left
shoulder—Kehr’s sign.
• There may be left sided haemothorax with fracture of ribs.
• Delayed presentation is also possible due to formation of
subcapsular haematoma which later gives way.
• Initially gets temporarily localized by greater omentum,
later giving way leading to torrential bleeding.
• Blood clot temporarily seals off the bleeding which later
gets dislodged causing severe bleeding.
• This time period in between is called ‘latent period of
Bandet’.
9. • Pseudoaneurysm and traumatic splenic
arteriovenous fistula formation can also
occasionally cause delayed life-threatening
haemorrhage.
• Features of other abdominal organ injuries
may be present.
10. Splenic organ injury scale 1994
• Grade 1
• Grade 2
• Non-expanding subcapsular
haematoma <10% surface area.
• Non-bleeding capsular
laceration with <1 cm depth
• Non-expanding subcapsular
haematoma 10–50% surface
area.
• Non-expanding
intraparenchymal haematoma
< 5 cm in diameter
• Laceration—capsular tear 1–3
cm in depth which does not
involve trabecular vessel
11. • Grade 3
• Grade 4
• Expanding subcapsular or >50%
surface area or ruptured bleeding
subcapsular haematoma /
intraparenchymal haematoma.
• Intraparenchymal haematoma >5
cm or parenchymal laceration >3
cm depth involving trabecular
vessels
• Laceration involving segmental or
hilar vessels with >25%
devascularization
• Grade V Shattered or avulsed
spleen; hilar devascularization
with entire spleen separation
12. Investigations
• U/S abdomen is the investigation of choice, as
it is quicker, cheaper and non-invasive.
• Hb%, PCV, blood grouping and cross
matching.
• Adequate amount of blood must be kept ready
for transfusion.
• CT scan will show type of splenic injury and
its class.
13. • Diagnostic peritoneal lavage (DPL): By subumbilical
incision the peritoneal lavage catheter is introduced into the
peritoneal cavity.
• One litre of crystalloid (normal saline) is introduced into the
cavity.
• Patient is turned to both left and right side and fluid is
collected back.
• It is sent for cytology, culture, microscopy and biochemical
analysis.
• It is significant when the aspirated fluid contains:
• Gross blood of 10 ml.
• >100000/mm3 of RBC
• >500/mm3 of WBC
• Bile, bacteria or food fibres
• Amylase > 175 units/dl
14. Complications in splenic rupture
• Blood loss
• DIC
• Sepsis
• Splenic artery pseudoaneurysm
• Splenic arteriovenous fistula
• Problems of associated injuries like of
pancreas
15. Management
Initial Management
• Central venous line for perfusion and
monitoring.
• Transfusion of blood as needed, resuscitation
using crystalloids like Ringer’s lactate.
• Antibiotics coverage.
• Urinary catheterisation.
• Nasogastric tube aspiration.
16. Surgery
Emergency splenectomy
• It is done through midline/left subcostal incision.
• Thoracoabdominal extension of incision may be needed
for rapid control of bleeding for injury to a large
tropical spleen with severe bleeding.
• Other associated injuries should be looked for and dealt
with (injury to left lobe liver/pancreas/intestine/colon).
Partial splenectomy (upper/lower).
• It can be done by retaining either of the upper or lower
polar branches of the splenic artery.
18. Splenorraphy
• In especially clean incised wound, spleen can be salvaged
by suturing the wound carefully with placement of gel
foam, topical thrombin, absorbable mesh wrap over the
wound.
• Suture repair, oxidised cellulose, debridement of lacerated
spleen—are other methods used.
• Temporary occlusion of splenic artery is often needed
during splenorrhaphy.
• 10% of splenic injuries undergo splenorrhaphy.
• Its application is getting reduced due to nonoperative
approach in such patients.
• But in class IV or V injuries splenorrhaphy is not possible.
![• The spleen can rupture as—Trauma to a
normal spleen OR to a diseased spleen
• Atraumatic rupture of a diseased spleen
[pathologic (occult) rupture] and Spontaneous
rupture of a normal spleen [spontaneous
(idiopathic) rupture].](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)