Introduction
Spleen, trauma. Chest radiograph shows a peripherally calcified mass in the left upper quadrant under the diaphragm. The mass represents a calcified splenic hematoma.
Spleen, trauma. Selective splenic arteriogram shows traumatic pseudoaneurysms with extravasation in the upper pole.
Background
The spleen is a functionally complex organ occupying the left upper quadrant (LUQ). It is an intraperitoneal organ weighing 75-100 g in the adult.
The spleen is the most vascular organ of the body, and approximately 350 L of blood passes through it per day. The spleen contains approximately 1 unit of blood at a given time. For this reason, splenic injury poses a potentially life-threatening situation. This risk is true especially because the spleen is the organ most commonly injured when thoracoabdominal trauma occurs, and splenic injuries represent approximately 25% of all blunt injuries to the abdominal viscera. Penetrating injuries also frequently involve the spleen along with other abdominal organs. The diagnosis of penetrating splenic injury is made easily because patients almost always are referred for surgery.1,2,3,4,5
Related eMedicine topics:
Splenic Abscess
Splenic Infarct
Splenic Rupture
Pathophysiology
Compared with other injuries, blunt injury to the spleen has a more deceptive and subtle presentation. Abdominal tenderness and distention are apparent in approximately 50% of patients, and hypotension is a presenting symptom in only 25-30% of patients. The patient's age and medical background also dictate the presentation and workup. The older, less healthy patient has a tendency to develop rapidly progressive hemodynamic instability, as compared with the younger, healthy patient. However, patients in unstable condition are not referred to the radiology department for diagnosis. Instead, they usually undergo peritoneal lavage, are referred for surgery, or both.
Patients with blunt abdominal trauma who are hemodynamically stable and who have minor or no symptoms can be found to have splenic injury radiographically, which is not to say that the workup serves little purpose. Diagnosing splenic trauma before the patient becomes significantly symptomatic is imperative. With the exception of splenic avulsion or shatter, lesser degrees of splenic rupture classically result in a delayed presentation with increased morbidity and mortality. Stable patients with splenic rupture require prompt diagnosis so that treatment can be initiated before systemic compromise ensues. In fact, the conservative treatment of splenic rupture has gained favor over recent years, and radiographic evaluation is more important now than ever. The role of the radiologist has continued to expand along with the data concerning splenic injuries and treatment options.
Frequency
United States
The true frequency of blunt abdominal injury is unknown because most patients probably do not seek medical attention. However, blunt abdominal trauma is the most common trauma-related diagnosis, and motor vehicle accidents are the most common cause. The spleen is injured in approximately 25-30% of cases.
Race
No significant racial predilection is noted in blunt splenic trauma.
Sex
Overall, a slight male predominance exists in blunt splenic trauma, with a male-to-female ratio of approximately 3:2. The reason for this difference is not completely clear, but it may be related to the increased participation in sports activities and manual-labor jobs among males, as well as their increased likelihood of driving motor vehicles. The frequency is slightly different in the pediatric population, in which injuries in males outnumber those in females by 2 to 1.
Age
Blunt splenic trauma affects all age groups. The incidence peaks in teenage patients and in middle-aged patients (primarily, those aged 15-35 years).
Anatomy
The spleen is protected by the rib cage anteriorly, laterally, and posteriorly. The position of the spleen is secured by several suspensory ligaments, including the gastrosplenic, splenorenal, splenocolic, and splenophrenic ligaments. The splenic vessels partially course through the gastrosplenic ligament, while the remaining ligaments are avascular in healthy individuals. However, these ligaments may contain large veins in the setting of portal hypertension. Physically, the spleen is in contact with many vital organs of the abdomen — namely, the left diaphragm superiorly, the pancreatic tail medially, the stomach anteromedially, the left kidney and adrenal gland posteromedially, and the splenic flexure inferiorly.
Arterial blood flow to the spleen is primarily via the splenic artery (SA). The SA arises from the celiac artery (CA) 82% of the time according to Michels.6 Alternative origins are the aorta and superior mesenteric artery (SMA). SA duplication is a rare finding. The left gastric artery is usually the first branch off the CA, with the SA and common hepatic artery forming a common trunk. The branches arise simultaneously in 25% of patients, and less often, the dorsal pancreatic artery (DPA) or middle colic artery also arises from the CA, creating a tetrapod configuration.
The SA averages 13 cm in length and has been divided into 4 anatomic segments as follows:
- The suprapancreatic segment represents the first 1-3 cm and is without branching for the most part.
- The pancreatic segment courses along the pancreas dorsally, supplying many branches to the organ. As the pancreas extends to the LUQ, it is located posteriorly and superiorly, with the SA assuming an anterior position with respect to the pancreatic tail.
- Called the prepancreatic segment at this point, the SA divides into many branches. Terminal branching occurs in this region 80% of the time, resulting in either 2 or 3 terminal arteries.
- The prehilar segment lies in the space between the pancreatic tail and spleen, with terminal branching occurring in this segment in the remaining 20% of patients.
Wide variation is the rule with respect to SA branching. The DPA can originate from the proximal SA, CA, SMA, or hepatic artery. The DPA supplies the pancreatic head and uncinate process and branches off into the transverse pancreatic artery (TPA). The TPA courses laterally along the inferior pancreatic margin to anastomose with the arteria pancreatica magna, which is the largest pancreatic branch of the SA. The TPA continues laterally to join the caudal pancreatic artery (CPA). The CPA arises from either the distal SA or left gastroepiploic artery (LGE). The origin of the LGE is from the distal SA just proximal to terminal branching or from the inferior terminal division. The LGE can provide significant blood flow to the inferior spleen through inferior polar branches.
The extensive arterial network of the pancreas is an important source of collateral splenic blood supply in the setting of SA occlusion. Another possible pathway is through anastomosis of the LGE with the right gastroepiploic artery off the gastroduodenal artery. This connection is termed the arcus arteriosus ventriculi inferior of Hyrtl.
SA terminal branching can take the form of superior terminal (ST) and inferior (90%) or superior, middle, and inferior divisions. Usually, the ST is the largest division supplying most of the splenic blood flow. Short gastric arteries to the gastric fundus commonly originate from the ST, as does the superior polar artery (SPA) to the superior spleen. Rarely, the SPA arises from the CA, creating a duplicated SA. Anastomosis of the short gastric arteries to the left gastric artery is another important pathway for collateral splenic blood flow.
Presentation
The patient with blunt splenic trauma can present in many ways. The clinical signs and symptoms vary widely. Some patients are asymptomatic, and others present in extremis.
The most common presenting complaint in a stable patient is left upper abdominal or flank pain; however, the pain is probably not significantly referable to the spleen but is related more to overlying soft tissue and/or bone injury and peritoneal irritation by the hemoperitoneum. This is supported by the prevalence of missed subcapsular hematomas with regard to more advanced degrees of splenic injury. This is not to say that the spleen contains no pain sensors; pain fibers are present within the splenic capsule, and they can elicit a strong response as proven by the severity of symptoms displayed during splenic infarction. The degree of pain elicited by a subcapsular hematoma is usually overlooked by clinicians and patients alike.
Preferred Examination
Although many plain radiographic findings suggest splenic injury, CT is the radiographic modality used at most institutions. CT scanning should be performed in conjunction with the intravenous administration of contrast material to maximize density differences between the splenic parenchyma and hematomas. In this fashion, CT provides the best evaluation of the spleen and the surrounding tissues. An additional advantage of CT is the ability to use it to image all of the abdominal organs simultaneously in excluding a secondary injury.
Many studies have been conducted to evaluate the imaging characteristics of splenic trauma with CT and to address the outcome of conservative treatment. Criteria for angiographic and surgical intervention based on these findings have been proposed in the literature and are discussed under CT SCAN, below.
Limitations of Techniques
The limitations of CT scanning are few but possibly important. The most detrimental limitation to confident interpretation of a CT scan is motion artifact. The sensitivity for the detection of a splenic injury decreases precipitously if the patient cannot remain still on the scanning table. Adequate sedation is essential in such patients. Overall, the sensitivity and specificity of CT in the detection of splenic injury is close to 100% in the authors' experience. Any deficiency in detection is usually a result of misinterpretation of the information and not an absence of findings.
Differential Diagnoses
Other Problems to Be Considered
For the most part, the diagnosis of splenic rupture is not particularly challenging; however, radiologists should be aware of the possible processes that may simulate splenic injury.
Foreign material
Occasionally, iatrogenically introduced material can demonstrate the appearance of splenic rupture on CT. In a typical trauma center, a nasogastric tube is placed, and contrast material is orally administered prior to CT examination. Streak artifact and beam-hardening artifact from the nasogastric tube and oral contrast medium, respectively, can overlay the spleen and cause confusion. Beam-hardening artifact from the ribs and streak artifact from gastric air-fluid levels can also produce false-positive results. A combination of these effects, together with poor-quality scans secondary to increased patient size, is fairly typical in everyday practice.
Hematoma
To some degree, hemoperitoneum always accompanies splenic injury, with the exception of an intact subcapsular process. However, not all intra-abdominal fluid represents hematoma. The radiologist must be wary of assuming that splenic injury is the cause if fluid is appreciated in the abdomen or around the spleen. Most blunt splenic trauma is seen in children struck by a motor vehicle, in those involved in an activity-related fall, or in occupants of motor vehicles involved in accidents. The greatest potential for false-positive results occurs in patients injured in motor vehicle accidents primarily because they tend to be older and have a higher rate of preexisting medical conditions.
Fluid accumulation
Liver, pancreatic, renal, and left-sided colon disease can lead to accumulation of fluid in the LUQ and inferior to the spleen. Other potential causes of fluid accumulation should not be forgotten; these include undiagnosed abdominal malignancy with ascites and peritoneal dialysis. Although many of these situations seem unlikely, the opportunity to obtain pertinent information from the patient may not exist. In most motor vehicle accidents, multiple individuals are injured. Elderly individuals tolerate even minor trauma poorly, and their hemodynamic status is commonly out of proportion to their apparent injuries. In addition, many trauma patients are combative upon their arrival to the hospital secondary to drug and alcohol use. The net result is that patients are transported to the radiology department after sedation or intubation.
Cysts
Many processes can affect the spleen and simulate laceration or intrasplenic hematoma. A seemingly endless list of etiologies related to splenic cyst has been reported in the literature. Any one of these causes may be misdiagnosed as splenic injury, but these should not be accompanied by abdominal fluid or hemoperitoneum. Splenic abscesses caused by bacterial endocarditis, splenic infarction, and invasive procedures can simulate splenic injury, and they may be associated with perisplenic fluid. Cystic lesions that mimic trauma can be classified by etiology as follows:
- Congenital – Epidermoid
- Vascular – Hematoma, posttraumatic cyst (80%), cystic infarct, and peliosis
- Inflammatory – Pyogenic abscess; fungal microabscess due to Candida, Aspergillus, or Cryptococcus species; tuberculosis; infection by Mycobacterium avium-intracellulare, Pneumocystis carinii, or Echinococcus species; and pancreatic pseudocyst
- Neoplastic – Cavernous hemangioma, angiosarcoma, lymphangioma, lymphoma, and metastasis (melanoma 50%)
Infarcts
Infarcts of the spleen can simulate the appearance of trauma. Classically, infarcts are well defined and wedge or triangular shaped. Infarcts extend from the outer margin with the apex pointing toward the splenic hilum. A thin rim of normal parenchyma can sometimes be seen along the outer margin. Although infarcts do not enhance, the outer rim may show enhancement along with the remainder of the spleen because of preserved capsular vessels. On sonograms and nonenhanced CT scans, infarcts can be confused with a laceration without perisplenic fluid.
Malignant tumors
Tumors of the spleen are uncommon overall. Most tumors of the spleen are related to lymphoma, which accounts for 70% of lesions. In addition, metastatic disease of the spleen is not uncommon, and melanoma, breast, lung, renal, and ovarian carcinomas are the leading primary cancers. These processes are hypoechoic on sonograms and hypoattenuating on CT scans, and they may simulate laceration or intraparenchymal blood. Metastatic disease can have associated ascites that simulates hemoperitoneum. Similar lesions in other organs and lymphadenopathy are usually present and exclude trauma. Lesion enhancement on contrast-enhanced CT scans is not demonstrated in blunt splenic trauma.
Benign tumors
The most common benign tumor of the spleen is the cavernous hemangioma. The tumor can be either hyperechoic or hypoechoic on sonograms and can simulate hematoma or noncoagulated blood, respectively. Hemangiomas appear hypoattenuating on CT scans, with variable contrast enhancement. Typically, the enhancement pattern is confined to the rim and fills in to become isoattenuating on delayed images. However, hemangiomas may not show contrast enhancement in a minority of patients. This finding is probably related to size of the lesion, with nonenhancement more commonly associated with smaller lesions.
Benign lesions can simulate parenchymal hematoma or small lacerations if near the periphery. The clue to correct diagnosis is the smooth distinct borders and rounded configuration of the hemangioma versus traumatic injury. Snowflake-like calcifications or phleboliths are uncommon, but they can differentiate tumor from trauma. Diffuse splenic hemangiomatosis is a condition in which the spleen is enlarged and replaced almost completely by hemangiomas. The striking appearance of the spleen can be dismissed as severe traumatic injury at first glance.
Splenic rupture
Nontraumatic splenic rupture is rare but has been associated with a number of disease processes. These entities may cause confusion, first because of their rarity and second because a traumatic etiology may be assumed. Careful inspection of the images usually leads to the correct diagnosis.
Sarcoidosis
Sarcoidosis is a disease of unknown etiology in which noncaseating granulomas form in tissues and organs of the body and have a predilection for the lymphatic system. The spleen is involved in 24-59% of patients with sarcoid but usually is asymptomatic. Those with marked involvement can develop abdominal symptoms. Severe cases can lead to hypersplenism and spontaneous rupture of uncertain etiology.7 Most commonly, the spleen is diffusely affected, and the findings can mimic those of lymphoma. Splenomegaly is apparent in approximately one third of patients and frequently shows associated lymphadenopathy. Discrete hypoattenuating nodules are present on CT scans in approximately 15% of patients; these result from aggregated granulomas.
Amyloidosis
The spleen is involved in amyloidosis, which is a disease in which plasma cells deposit amyloid, a complex protein made mostly of polypeptide chains, throughout the tissues and organs. Amyloidosis can be primary or secondary, related to chronic inflammation (most notably rheumatoid arthritis), and occurs in association with multiple myeloma.
The spleen is affected in all forms of amyloidosis and appears diffuse and homogeneous in most patients. Diffuse decreased splenic attenuation with contrast enhancement can be seen on CT scans, but focal abnormalities, which can mimic laceration, are also possible. Spontaneous splenic rupture, believed to result from capsular weakening from amyloid deposition, has been reported.8 Decreased attenuation in other involved organs (eg, liver and kidneys) can aid in distinguishing amyloidosis from a traumatic etiology. In addition, amyloid deposition in the retroperitoneal fat and mesentery leads to increased attenuation on CT scans.
Infection
Bartonella organisms are gram-negative bacilli originally considered to primarily infect patients with HIV infection. However, recent studies have demonstrated a Bartonella species to be the causative organism of catscratch disease. Therefore, the bacteria can infect immunocompetent individuals as well. Two primary infectious processes result from infection by Bartonella organisms; the form involving the liver and spleen is called bacillary peliosis hepatis.
Pathologically, the bacilli cause capillary dilation, resulting in numerable thin-walled, blood-filled cavities throughout the liver and spleen. Abdominal CT shows multiple low-attenuating lesions in the liver and spleen with associated lymphadenopathy and possible ascites. Lesions can coalesce to form multiloculated or septated lesions demonstrating variable contrast enhancement. Spontaneous splenic rupture has been reported in patients with bacillary peliosis hepatis.9 A similar appearing process has been described related to the use of oral contraceptives, chemotherapeutic agents, and anabolic steroids, but the etiology of these processes remains obscure.
Secondary trauma
Any of the processes mentioned above may predispose the spleen to rupture, resulting in trivial degrees of trauma. A spleen enlarged by tumor masses or anemia may be injured with a simple fall on the sidewalk. A peripherally situated hemangioma or cyst may rupture with apparently insignificant trauma because of a weakened overlying capsule. These conditions are associated with hemoperitoneum or parenchymal hemorrhage and are virtually indistinguishable from simple splenic trauma.
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Further Reading
Keywords
spleen trauma, splenic injury, spleen injury, blunt injury to the spleen, splenic trauma
