Splenic Rupture Workup

  • Author: H Scott Bjerke, MD, FACS; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Jan 20, 2012
 

Laboratory Studies

  • While frequently obtained, a complete blood cell count or hemoglobin level is rarely helpful in the initial workup of the suspected splenic injury. These are helpful in providing baseline values and, when performed serially, in diagnosing ongoing blood loss or hemodilution due to volume resuscitation.
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Imaging Studies

  • Focused abdominal sonographic technique
    • FAST, observing for the presence or absence of fluid in the peritoneal cavity, may be performed rapidly and safely in trauma patients.
    • FAST is poor for delineating organ-specific anatomy with any reliability in the emergency setting. In addition, the learning and interpretation curve is rather steep when compared to DPL.
    • In experienced hands, visualization of fluid in the right upper quadrant, the left upper quadrant, and the pelvis suggests solid organ injury (or mesenteric injury) and the possibility of splenic injury.
  • CT scanning
    • In the stable patient, CT scanning provides structural evaluation of the spleen and surrounding organs.
    • Intravenous contrast injected at the time of scan improves the clinician's ability to determine the severity of injury. Active bleeding from the splenic parenchyma can be missed with a noncontrast CT scan.
    • A splenic contrast blush noted by a helical CT scanner has a greater propensity to require splenic exploration in most series.[8, 9] See the image below. Intra-parenchymal blush observed on helical CT scaIntra-parenchymal blush observed on helical CT scan.
    • Multidetector CT scanners have improved diagnostic capabilities but may still miss some vascular injuries.[10]
  • Angiography
    • Angiography is rarely the first choice for evaluation of the patient with a splenic injury, but it is being used more frequently for primary therapeutic management of splenic injuries.
    • Angiography is usually performed after CT scanning images are obtained showing an arterial contrast blush or active extravasation. Angiography is less of a diagnostic modality and more of a preparation for therapeutic angioembolization of active bleeding sites.
  • MRI has been reported as an option in the patient with renal failure or significant contrast allergy.
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Other Tests

  • Radioisotope studies
    • These are rarely helpful in this day of rapid, detailed, high-resolution CT scanners.
    • These studies should probably be eschewed as a diagnostic option in the trauma patient unless no other confirmatory tests are available.
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Diagnostic Procedures

  • Diagnostic peritoneal lavage
    • DPL is a method of rapidly determining if free intraperitoneal blood is present. This test is especially useful in the hypotensive patient.
    • DPL is fast and inexpensive. It has a low complication rate in experienced hands.
    • FAST has replaced DPL in many institutions because it is less invasive, but it has not yet been shown to be more sensitive or specific than DPL in most published studies.
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Histologic Findings

Histologic findings may help to explain why a minor trauma resulted in a major splenic injury. Splenic rupture may follow after a seemingly minor transfer of kinetic energy because of organ expansion with capsular thinning or an abnormal internal architecture with reduced elasticity to the parenchyma. Such events may happen with splenomegaly due to hematologic abnormalities (eg, hereditary spherocytosis), infectious diseases (eg, malaria), and liver disease (eg, portal and splenic hypertension).

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Staging

Splenic injury is graded using the standards published by the Organ Injury Scaling Committee of the AAST. Categories range from grade I (minor) to grade V (major) and correlate to the need for laparotomy. These grades are used in conjunction with nonoperative assessment (eg, CT scanning, angiography), operative intervention by laparotomy, or postmortem by autopsy. Some studies comparing CT staging with operative staging indicate that CT scanning overestimates the injury by as much as 10%. However, CT scan findings correlate well with the need for operative intervention.

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Contributor Information and Disclosures
Author

H Scott Bjerke, MD, FACS  Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine and Biosciences

H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Janet S Bjerke, RN, MBA, CCRC  Research Coordinator, Trauma Services, Methodist Hospital of Indianapolis

Janet S Bjerke, RN, MBA, CCRC is a member of the following medical societies: Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Lewis J Kaplan, MD, FACS, FCCM, FCCP  Director, SICU and Surgical Critical Care Fellowship, Associate Professor, Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale University School of Medicine

Lewis J Kaplan, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Association for Surgical Education, Connecticut State Medical Society, Eastern Association for the Surgery of Trauma, International Trauma Anesthesia and Critical Care Society, Society for the Advancement of Blood Management, Society of Critical Care Medicine, and Surgical Infection Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert L Sheridan, MD  Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

References

  1. Harbrecht BG, Franklin GA, Miller FB, Richardson JD. Is splenectomy after trauma an endangered species?. Am Surg. May 2008;74(5):410-2. [Medline].

  2. Fishback SJ, Pickhardt PJ, Bhalla S, Menias CO, Congdon RG, Macari M. Delayed presentation of splenic rupture following colonoscopy: clinical and CT findings. Emerg Radiol. Dec 2011;18(6):539-44. [Medline].

  3. Ha JF, Minchin D. Splenic injury in colonoscopy: a review. Int J Surg. Jul 26 2009;epub ahead of print. [Medline].

  4. Rozycki GS, Knudson MM, Shackford SR. Surgeon-performed bedside organ assessment with sonography after trauma (BOAST): a pilot study from the WTA Multicenter Group. J Trauma. Dec 2005;59(6):1356-64.

  5. Sirlin CB, Casola G, Brown MA. Patterns of fluid accumulation on screening ultrasonography for blunt abdominal trauma: comparison with site of injury. J Ultrasound Med. Apr 2001;20(4):351-7.

  6. Hedrick TL, Sawyer RG, Young JS. MRI for the diagnosis of blunt abdominal trauma: a case report. Emerg Radiol. Jul 2005;11(5):309-11.

  7. Lin WC, Chen YF, Lin CH, Tzeng YH, Chiang HJ, Ho YJ. Emergent transcatheter arterial embolization in hemodynamically unstable patients with blunt splenic injury. Acad Radiol. Feb 2008;15(2):201-8. [Medline].

  8. Willmann JK, Roos JE, Platz A. Multidetector CT: detection of active hemorrhage in patients with blunt abdominal trauma. AJR Am J Roentgenol. Aug 2002;179(2):437-44. [Medline].

  9. Nwomeh BC, Nadler EP, Meza MP. Contrast extravasation predicts the need for operative intervention in children with blunt splenic trauma. J Trauma. Mar 2004;56(3):537-41.

  10. Marmery H, Shanmuganathan K, Mirvis SE, Richard H 3rd, Sliker C, Miller LA, et al. Correlation of multidetector CT findings with splenic arteriography and surgery: prospective study in 392 patients. J Am Coll Surg. Apr 2008;206(4):685-93. [Medline].

  11. Vick LR, Islam S. Recombinant factor VIIa as an adjunct in nonoperative management of solid organ injuries in children. J Pediatr Surg. Jan 2008;43(1):195-8; discussion 198-9. [Medline].

  12. Sims CA, Wiebe DJ, Nance ML. Blunt solid organ injury: do adult and pediatric surgeons treat children differently?. J Trauma. Sep 2008;65(3):698-703. [Medline].

  13. Shatz DV, Schinsky MF, Pais LB, et al. Immune responses of splenectomized trauma patients to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy. J Trauma. May 1998;44(5):760-5; discussion 765-6. [Medline].

  14. Shatz DV, Romero-Steiner S, Elie CM, Holder PF, Carlone GM. Antibody responses in postsplenectomy trauma patients receiving the 23-valent pneumococcal polysaccharide vaccine at 14 versus 28 days postoperatively. J Trauma. Dec 2002;53(6):1037-42. [Medline].

  15. Killeen KL, Shanmuganathan K, Boyd-Kranis R. CT findings after embolization for blunt splenic trauma. J Vasc Interv Radiol. Feb 2001;12(2):209-14. [Medline].

  16. Ekeh AP, McCarthy MC, Woods RJ. Complications arising from splenic embolization after blunt splenic trauma. Am J Surg. Mar 2005;189(3):335-9.

  17. Wu HM, Kortbeek JB. Management of splenic pseudocysts following trauma: a retrospective case series. Am J Surg. May 2006;191(5):631-4.

  18. Runyan BL, Smith RS, Osland JS. Progressive splenomegaly following splenic artery embolization. Am Surg. May 2008;74(5):437-9. [Medline].

  19. Hamers RL, Van Den Berg FG, Groeneveld AB. Acute necrotizing pancreatitis following inadvertent extensive splenic artery embolisation for trauma. Br J Radiol. Jan 2009;82(973):e11-4. [Medline].

  20. Bjerke S, Pohlman T, Saywell RM. Evolution, not revolution: splenic salvage for blunt trauma in a statewide voluntary trauma system--a 10-year experience. Am J Surg. Mar 2006;191(3):413-7.

  21. Harbrecht BG, Zenati MS, Ochoa JB. Management of adult blunt splenic injuries: comparison between level I and level II trauma centers. J Am Coll Surg. Feb 2004;198(2):232-9.

  22. Carlin AM, Tyburski JG, Wilson RF. Factors affecting the outcome of patients with splenic trauma. Am Surg. Mar 2002;68(3):232-9.

  23. Amonkar SJ, Kumar EN. Spontaneous rupture of the spleen: three case reports and causative processes for the radiologist to consider. Br J Radiol. Jun 2009;82(978):e111-3. [Medline].

  24. Bain IM, Kirby RM. 10 year experience of splenic injury: an increasing place for conservative management after blunt trauma. Injury. Apr 1998;29(3):177-82. [Medline].

  25. Bain IM, Kirby RM, Cook AL. Role of the general surgeon in a British trauma centre. Br J Surg. Sep 1996;83(9):1248-51. [Medline].

  26. Barone JE, Burns G, Svehlak SA. Management of blunt splenic trauma in patients older than 55 years. Southern Connecticut Regional Trauma Quality Assurance Committee. J Trauma. Jan 1999;46(1):87-90. [Medline].

  27. Bianchi JD, Collin GR. Management of splenic trauma at a rural, Level I trauma center. Am Surg. Jun 1997;63(6):490-5. [Medline].

  28. Caplan ES, Boltansky H, Snyder MJ. Response of traumatized splenectomized patients to immediate vaccination with polyvalent pneumococcal vaccine. J Trauma. Sep 1983;23(9):801-5. [Medline].

  29. Cathey KL, Brady WJ Jr, Butler K. Blunt splenic trauma: characteristics of patients requiring urgent laparotomy. Am Surg. May 1998;64(5):450-4. [Medline].

  30. Clancy TV, Ramshaw DG, Maxwell JG. Management outcomes in splenic injury: a statewide trauma center review. Ann Surg. Jul 1997;226(1):17-24. [Medline].

  31. Clancy TV, Weintritt DC, Ramshaw DG. Splenic salvage in adults at a level II community hospital trauma center. Am Surg. Dec 1996;62(12):1045-9. [Medline].

  32. Coburn MC, Pfeifer J, DeLuca FG. Nonoperative management of splenic and hepatic trauma in the multiply injured pediatric and adolescent patient. Arch Surg. Mar 1995;130(3):332-8. [Medline].

  33. Cocanour CS, Moore FA, Ware DN. Age should not be a consideration for nonoperative management of blunt splenic injury. J Trauma. Apr 2000;48(4):606-10; discussion 610-2. [Medline].

  34. Cocanour CS, Moore FA, Ware DN. Delayed complications of nonoperative management of blunt adult splenic trauma. Arch Surg. Jun 1998;133(6):619-24; discussion 624-5. [Medline].

  35. Cochran A, Mann NC, Dean JM. Resource utilization and its management in splenic trauma. Am J Surg. Jun 2004;187(6):713-9.

  36. Cohn SM, Arango JI, Myers JG, Lopez PP, Jonas RB, Waite LL, et al. Computed tomography grading systems poorly predict the need for intervention after spleen and liver injuries. Am Surg. Feb 2009;75(2):133-9. [Medline].

  37. Daoud RA, Taghizadeh AK, Pickford RB. Conservative management of splenic trauma. J R Army Med Corps. Jun 1999;145(2):69-72. [Medline].

  38. Ekeh AP, Izu B, Ryan M, McCarthy MC. The impact of splenic artery embolization on the management of splenic trauma: an 8-year review. Am J Surg. Mar 2009;197(3):337-41. [Medline].

  39. Garber BG, Yelle JD, Fairfull-Smith R. Management of splenic injuries in a Canadian trauma centre. Can J Surg. Dec 1996;39(6):474-80. [Medline].

  40. Gaunt WT, McCarthy MC, Lambert CS. Traditional criteria for observation of splenic trauma should be challenged. Am Surg. Jul 1999;65(7):689-91; discussion 691-2. [Medline].

  41. Guth AA, Pachter HL, Jacobowitz GR. Rupture of the pathologic spleen: is there a role for nonoperative therapy?. J Trauma. Aug 1996;41(2):214-8. [Medline].

  42. Harbrecht BG, Peitzman AB, Rivera L, et al. Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma. J Trauma. Nov 2001;51(5):887-95.

  43. Harbrecht BG, Zenati MS, Alarcon LH. Is outcome after blunt splenic injury in adults better in high-volume trauma centers?. Am Surg. Nov 2005;71(11):942-8; discussion 948-9.

  44. Ivatury RR, Simon RJ, Guignard J. The spleen at risk after penetrating trauma. J Trauma. Sep 1993;35(3):409-14. [Medline].

  45. Keller MS, Vane DW. Management of pediatric blunt splenic injury: comparison of pediatric and adult trauma surgeons. J Pediatr Surg. Feb 1995;30(2):221-4; discussion 224-5. [Medline].

  46. Kilic N, Gurpinar A, Kiristioglu I. Ruptured spleen due to blunt trauma in children: analysis of blood transfusion requirements. Eur J Emerg Med. Jun 1999;6(2):135-9. [Medline].

  47. Krause KR, Howells GA, Bair HA. Nonoperative management of blunt splenic injury in adults 55 years and older: a twenty-year experience. Am Surg. Jul 2000;66(7):636-40. [Medline].

  48. Krupnick AS, Teitelbaum DH, Geiger JD. Use of abdominal ultrasonography to assess pediatric splenic trauma. Potential pitfalls in the diagnosis. Ann Surg. Apr 1997;225(4):408-14. [Medline].

  49. Lawson DE, Jacobson JA, Spizarny DL. Splenic trauma: value of follow-up CT. Radiology. Jan 1995;194(1):97-100. [Medline].

  50. Lucas CE. Splenic trauma. Choice of management. Ann Surg. Feb 1991;213(2):98-112. [Medline].

  51. Morrell DG, Chang FC, Helmer SD. Changing trends in the management of splenic injury. Am J Surg. Dec 1995;170(6):686-9; discussion 690. [Medline].

  52. Myers JG, Dent DL, Stewart RM. Blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of nonoperative success in patients of all ages. J Trauma. May 2000;48(5):801-5; discussion 805-6. [Medline].

  53. Novelline RA, Rhea JT, Bell T. Helical CT of abdominal trauma. Radiol Clin North Am. May 1999;37(3):591-612, vi-vii. [Medline].

  54. Pachter HL, Guth AA, Hofstetter SR. Changing patterns in the management of splenic trauma: the impact of nonoperative management. Ann Surg. May 1998;227(5):708-17; discussion 717-9. [Medline].

  55. Peitzman AB, Heil B, Rivera L. Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma. J Trauma. Aug 2000;49(2):177-87; discussion 187-9. [Medline].

  56. Pisters PW, Pachter HL. Autologous splenic transplantation for splenic trauma. Ann Surg. Mar 1994;219(3):225-35. [Medline].

  57. Poulin EC, Thibault C, DesCoteaux JG. Partial laparoscopic splenectomy for trauma: technique and case report. Surg Laparosc Endosc. Aug 1995;5(4):306-10. [Medline].

  58. Ransom KJ, Kavic MS. Laparoscopic splenectomy for blunt trauma: a safe operation following embolization. Surg Endosc. Feb 2009;23(2):352-5. [Medline].

  59. Rappaport WD, McIntyre KE, Stanton C. The effect of alcohol in isolated blunt splenic trauma. J Trauma. Dec 1990;30(12):1518-20. [Medline].

  60. Rose AT, Newman MI, Debelak J. The incidence of splenectomy is decreasing: lessons learned from trauma experience. Am Surg. May 2000;66(5):481-6. [Medline].

  61. Rutherford EJ, Livengood J, Higginbotham M. Efficacy and safety of pneumococcal revaccination after splenectomy for trauma. J Trauma. Sep 1995;39(3):448-52. [Medline].

  62. Rutledge R, Hunt JP, Lentz CW. A statewide, population-based time-series analysis of the increasing frequency of nonoperative management of abdominal solid organ injury. Ann Surg. Sep 1995;222(3):311-22; discussion 322-6. [Medline].

  63. Schurr MJ, Fabian TC, Gavant M. Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of nonoperative management. J Trauma. Sep 1995;39(3):507-12; discussion 512-3. [Medline].

  64. Shatz DV. Vaccination practices among North American trauma surgeons in splenectomy for trauma. J Trauma. Nov 2002;53(5):950-6. [Medline].

  65. Smith J, Armen S, Cook CH, Martin LC. Blunt splenic injuries: have we watched long enough?. J Trauma. Mar 2008;64(3):656-63; discussion 663-5. [Medline].

  66. vick lr.

  67. Wasvary H, Howells G, Villalba M. Nonoperative management of adult blunt splenic trauma: a 15-year experience. Am Surg. Aug 1997;63(8):694-9. [Medline].

  68. Williams RA, Black JJ, Sinow RM. Computed tomography-assisted management of splenic trauma. Am J Surg. Sep 1997;174(3):276-9. [Medline].

 
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Hemisplenectomy (splenorrhaphy) with preservation of greater than 50% of splenic parenchyma.
Intra-parenchymal blush observed on helical CT scan.
Physical findings in postsplenectomy sepsis with peripheral thrombosis and disseminated intravascular coagulation (DIC).
Grade 4-5 splenic laceration on helical CT scan.
 
 
 
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