The document provides a comprehensive overview of splenic rupture caused by blunt or penetrating trauma, detailing its etiology, clinical features, diagnostic investigations, and treatment protocols. Nonoperative management is feasible for hemodynamically stable patients, while operative management is required for those in distress or failing conservative treatment. It also highlights potential complications such as overwhelming post-splenectomy infection (OPSI) and emphasizes the importance of vaccination prior to discharge.

1. SPLENIC
RUPTURE
DR.B.SELVARAJ MS;Mch;FICS;
‘Surgical Educator’
MALAYSIA
BLUNT ABDOMINAL
TRAUMA

2. SPLENIC RUPTURE
• Etiology
• Pathology
• Clinical features
• Workup/Investigations
• Differential diagnosis
• Splenic CT injury grading
• Treatment
• Complications- OPSI
• Treatment algorithm for Splenic injury
LEARNING OBJECTIVES

3. SPLENIC RUPTURE
• H/O Blunt abdominal or lower thoracic trauma
• Penetrating trauma to Left Hypochondrium
• Iatrogenic
• Spontaneous rupture
- Malaria
- Leukemia
- Infectious mononucleosis
ETIOLOGY
• Injury types
• Laceration
• Hilar injury
• Subcapsular hematoma
• Injury associated with other organ
injuries
• Mechanism of injury
• Crushing
• Deceleration
• Sudden increase in intra abdominal
pressure

4. SPLENIC RUPTURE
• Classically associated with left lower ribs fracture
• Delayed rupture is a characteristic feature in
Subcapsular hematoma
• A ruptured spleen can cause life-threatening
bleeding into the abdominal cavity.
PATHOLOGY

5. SPLENIC RUPTURE
• H/O Trauma
• Pain abdomen
• Occasional distension and vomiting
• In severe bleeding associated with shock, syncope or
dizziness
• Kher’s sign Pain over left shoulder joint
• Fixed dullness to percussion on the left, and shifting
dullness on the right (Ballance’s sign).
• Tenderness all over the abdomen with or without
guarding and rigidity
• Bowel sounds are absent
CLINICAL FEATURES

6. SPLENIC RUPTURE
• Other causes for hemoperitoneum
• Liver injury
• Ruptured ectopic pregnancy
• Ruptured abdominal aortic aneurysm
• Acute hemorrhagic pancreatitis
DIFFERENTIAL DIAGNOSIS

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INVESTIGATIONS

8. SPLENIC RUPTURE
INVESTIGATIONS- CECT
 CT is the procedure of choice for diagnosis and
estimation of the degree of splenic injury in the
hemodynamically normal patient.
 Contrast blush (intraparenchymal hyperdense
contrast collection)suggests active hemorrhage and
is associated with failure of nonoperative
management in all solid organ injuries.

9. SPLENIC RUPTURE
INVESTIGATIONS
SELECTIVE CELIAC ARTERIOGRAPHY
 Angiography may be
used in patients
demonstrating a
contrast blush on CT
scan to identify and
treat a vascular
abnormality

10. SPLENIC RUPTURE
INVESTIGATIONS DPA/DPL

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AAST – CT GRADING

12. SPLENIC RUPTURE
TREATMENT
Nonoperative management
 Requires ICU monitoring in a dedicated
trauma center and immediate ability to
convert to operative management should
that become necessary
Indications
 Hemodynamic stability
 Minimal evidence of blood loss, < 2 units
packed red blood cells as transfusion
requirement
 Absence of active contrast extravasation on
CT scan
 Absence of other indication for laparotomy
 Length of intensive care unit (ICU) monitoring is generally
24 to 48 hours initially, with serial hematocrit evaluation
and continuous hemodynamic monitoring
 Blood transfusion is limited to 2 units of packed red blood
cells. If the patient has an ongoing transfusion
requirement of more than 2 units, operative management
should be performed
 The majority of pediatric splenic trauma is successfully
managed nonoperatively.
 Recovery recommendations include restricted activity in
terms of contact sports, running, or similar stresses for 3
months following injury.
 Angiography is performed in patients who are
hemodynamically normal and have a blush on initial CT
scan.

13. SPLENIC RUPTURE
TREATMENT
Operative management
 Should be performed in those patients
demonstrating peritonitis or
hemodynamic instability, those failing
nonoperative therapy, and those with
gunshot wounds to the abdomen
 Splenectomy is indicated with
significant blood loss (>1000 mL),
significant associated injuries, hilar
involvement, coagulopathy, or massive
splenic disruption
 Splenic salvage includes splenorrhaphy
and partial splenectomy
 Splenorrhaphy can be performed with
absorbable mesh (Dexon)
 Other strategies include the use of topical hemostatic
agents, including Surgicel, Avitene, and topical thrombin,
as well as the application of mattress sutures to allow
tamponade of hemorrhage.
 Partial splenectomy may be performed for polar injuries. At
least 30% of the spleen must be preserved to maintain
function.

14. SPLENIC RUPTURE
TREATMENT
Operative management
 In stable patient without
fecal contamination
- Splenic replantation
- 15 slices of spleen
implanted in greater
omentum in three rows
Triple decker omental
sandwich

15. SPLENIC RUPTURE
COMPLICATIONS
 Atelectasis which should be treated with
aggressive pulmonary toileting
 Delayed bleeding in subcapsular hematoma
 Subpherenic abscess
 Pancreatic injury resulting Pancreatic fistula
 Thrombocytosis if platelets are > 10,00,000
 OPSI- Overwhelming Post Splenectomy
Infection

16. SPLENIC RUPTURE
OPSI
 Syndrome consists of rapid development of
severe sepsis with hypotension, disseminated
intravascular coagulation, respiratory distress,
and coma within hours of presentation
 Incidence. This is a rare complication of
splenectomy. 50% to 70% of OPSI occurs less
than 2 years after splenectomy.
 Mortaltiy is 50% to 70% for patients
presenting with full-blown OPSI
 Organisms. S. pneumoniae is responsible for
50% to 90% of infections. Others include N.
meningitides, H. influenzae
 Treatment. Aggressive empiric antibiotic therapy
should be initiated awaiting pan-
culture/sensitivities.
 Prophylaxis. Presplenectomy immunization (2 weeks
before splenectomy) is optimal but most often
impossible for traumatic splenectomy.
 Immunization for Pneumococcus, Meningococcus,
and H. influenzae type B should be administered
prior to discharge Pneumovax. Pneumococcal
booster should be considered every 5 to 6 years for
high-risk patients.

17. SPLENIC RUPTURE

18. HAND-WRITTEN MINDMAP